Differential Diagnosis of Backache: A Comprehensive Guide for Automotive Repair Experts

Introduction

Back pain stands as a ubiquitous complaint, frequently prompting individuals to seek medical attention, including emergency services. Its persistent nature can lead to considerable disability in affected individuals. While back pain can afflict people of all ages and often stems from mechanical or nonspecific origins, the underlying causes vary across different age groups. This variation is crucial for clinicians in formulating effective treatment strategies.

This article provides an in-depth exploration of the diverse landscape of back pain. Designed for automotive repair experts, who often encounter back pain due to the physically demanding nature of their profession, this guide aims to equip you with the knowledge to understand and differentiate the various sources of back pain. Recognizing red flags indicative of severe conditions and understanding the principles of differential diagnosis are essential, not only for personal well-being but also for advising colleagues and employees in physically strenuous roles. This article will also delve into evidence-based conservative management approaches for nonspecific back pain, emphasizing the importance of maintaining physical activity over relying solely on pharmacological interventions. By understanding these concepts, automotive repair experts can better manage their own back health and promote a healthier work environment.

Back pain incurs significant economic burden, with estimated annual costs reaching $200 billion in management and lost productivity. Mechanical back pain, accounting for approximately 90% of cases, often overshadows rarer, but potentially serious, etiologies. Therefore, it is critical to be vigilant in identifying red flags and determining the most appropriate course of action. While most back pain can be managed conservatively, the presence of nerve dysfunction or other alarming signs necessitates thorough investigation and a multidisciplinary approach.

Treatment options range from pharmacological interventions targeting pain pathways to non-pharmacological approaches like physical therapy and alternative therapies such as acupuncture. Surgery is reserved for cases involving severe nerve dysfunction or serious underlying conditions like malignancy. Imaging techniques, including radiography, CT scans, and MRI, are typically considered if back pain persists beyond 6 weeks after an acute injury. A comprehensive evaluation is paramount in determining the root cause of back pain and developing a personalized treatment plan, ultimately improving functional capacity and quality of life.

Etiology of Back Pain

Back pain can arise from a multitude of conditions, broadly categorized as follows:

Traumatic: These injuries result from external forces, either direct or indirect. Examples relevant to automotive repair experts include strains from lifting heavy parts, whiplash injuries from vehicle accidents, and fractures from falls in the workshop.
Degenerative: Over time, the musculoskeletal structures of the back can weaken due to aging, repetitive strain, and pre-existing conditions. This is particularly relevant in professions with heavy lifting and awkward postures. Conditions like intervertebral disc herniation and degenerative disc disease are common examples.
Oncologic: Primary or secondary malignant lesions can develop in the back’s anatomical structures. Pathologic fractures of the spine can also occur as a complication, though less common, it’s important to be aware of, especially with persistent unexplained back pain.
Infectious: Infections of the musculoskeletal structures can arise from direct inoculation (e.g., post-surgical infection, penetrating trauma) or spread from another infection site. While less frequent, infections can be serious and require prompt medical attention.
Inflammatory: This category includes inflammatory conditions not caused by infection or malignancy. Examples include ankylosing spondylitis and sacroiliitis. Chronic inflammation can lead to spinal arthritis, potentially exacerbated by physically demanding work.
Metabolic: Disruptions in calcium and bone metabolism, such as osteoporosis and osteosclerosis, can contribute to back pain. These conditions can increase susceptibility to fractures and pain, especially with heavy lifting or sudden movements.
Referred Pain: Pain originating from visceral organs can be referred to the back. Examples include biliary colic, lung disease, and aortic or vertebral artery pathology. While less common in the context of automotive work-related back pain, these possibilities should be considered in persistent or atypical cases.
Postural: Prolonged periods in upright positions, especially with poor posture, can cause back pain. Automotive repair work often involves prolonged standing, bending, and awkward postures, predisposing individuals to postural back pain.
Congenital: Inborn conditions affecting the axial skeleton, such as kyphoscoliosis and tethered spinal cord, can manifest as back pain. While these are present from birth, they may become symptomatic later in life, especially with physical stress.
Psychiatric: Back pain can also be associated with chronic pain syndromes and mental health conditions. It’s important to acknowledge the psychological component of chronic pain, as stress and mental well-being can significantly influence pain perception and management.

The duration of back pain (acute vs. chronic) is also crucial, as acute and chronic pain often have different underlying causes. A thorough clinical evaluation and appropriate diagnostic examinations are typically sufficient to pinpoint the exact cause. Depending on the findings, referral to specialists like orthopedic surgeons, neurologists, rheumatologists, or pain management specialists may be necessary for further evaluation and treatment planning.

Epidemiology of Back Pain

Back pain is a widespread health issue among adults globally. Studies indicate that up to 23% of adults worldwide experience chronic low back pain, with recurrence rates ranging from 24% to 80% within a year. The lifetime prevalence of back pain in adults is remarkably high, reaching up to 84%. This underscores the pervasive nature of back pain and its significant impact on adult populations.

While less prevalent in children and adolescents, back pain is not uncommon in younger populations. Studies have shown that the point prevalence of back pain in children is approximately 1% for 12-year-olds and 5% for 15-year-olds. By late adolescence and early adulthood (age 18 for girls and 20 for boys), about 50% will have experienced at least one episode of back pain. The lifetime prevalence of back pain in adolescents increases steadily with age, approaching adult levels by the age of 18. This highlights the importance of addressing back pain even in younger individuals and promoting preventative measures early in life.

History and Physical Examination in Back Pain

Determining the cause of back pain begins with a detailed history and physical examination. The onset of pain is a critical initial step. Acute back pain, lasting less than 6 weeks, is often triggered by trauma or sudden changes in chronic conditions. Chronic back pain, persisting for more than 12 weeks, may be mechanically related or due to long-standing conditions.

Understanding factors that provoke or alleviate the pain is essential. This information provides diagnostic clues and guides the clinician in determining appropriate pain management strategies. For example, pain that worsens with bending and lifting might suggest mechanical strain, while pain relieved by rest might point towards a different etiology.

The quality of pain can help differentiate between visceral and non-visceral sources. Well-localized pain is often indicative of an organic process within the musculoskeletal system. Associated symptoms provide further clues about the origin of back pain. For instance, radiating pain down the leg might suggest nerve involvement (radiculopathy), while fever and night sweats could indicate infection or malignancy.

Relevant information from the patient’s medical, family, occupational, and social history is crucial. A history of cancer chemotherapy raises suspicion of metastasis or secondary tumors. Family history of autoimmune conditions might suggest inflammatory arthritis. Occupational history, particularly involving prolonged sitting, heavy lifting, or repetitive movements, is highly relevant in automotive repair professionals.

A focused physical examination includes inspection, auscultation, palpation, and provocative maneuvers. Visual inspection may reveal deformities, signs of inflammation, or skin lesions. Auscultation is valuable when pulmonary pathology is suspected. Palpation can identify localized musculoskeletal tenderness.

Provocative exercises can provide clues about the cause of back pain. The straight-leg-raising (SLR) test is useful for diagnosing lumbar disc herniation. This test involves raising the patient’s leg to between 30° and 70°. A positive result is indicated by ipsilateral leg pain developing at less than 60°. The crossed SLR test, where the leg contralateral to the herniated disc is raised, is even more specific.

The Stork test assesses for spondylolysis. The patient stands on one leg and hyperextends the back, supported by the examiner. The test is positive if pain occurs during hyperextension.

The Adam test evaluates for scoliosis. The patient bends forward with feet together, arms extended, and palms together. A thoracic lump in patients with scoliosis can be observed by an examiner standing in front.

Assessing range of motion, limb strength, deep tendon reflexes, and sensation helps evaluate the integrity of both the musculoskeletal and neurological systems.

Certain red flags identified during history or physical examination warrant imaging and further diagnostic testing. These red flags, categorized by adult and pediatric populations, include:

Red Flags for Back Pain in Adults:

Malignancy:
- History: History of metastatic cancer, unexplained weight loss, prior cancer diagnosis.
- Physical Exam: Focal tenderness to palpation, especially in patients with cancer risk factors.
Infection:
- History: Recent spinal procedure (within 12 months), intravenous drug use, immunosuppression, prior lumbar spine surgery.
- Physical Exam: Fever, wound in the spinal region, localized pain, tenderness, signs of systemic illness.
Fracture:
- History: Significant trauma (relative to age), prolonged corticosteroid use, osteoporosis, age older than 70 years. In the context of automotive work, falls from height or vehicle accidents.
- Physical Exam: Contusions, abrasions, tenderness to palpation over spinous processes, spinal deformity.
Neurologic:
- History: Progressive motor or sensory loss, new urinary retention or incontinence, new fecal incontinence, saddle anesthesia.
- Physical Exam: Saddle anesthesia, anal sphincter atony, significant motor deficits in multiple myotomes, reflex abnormalities.

Red Flags for Back Pain in Pediatric Patients:

Malignancy:
- History: Age younger than 4 years, nighttime pain, unexplained weight loss.
- Physical Exam: Focal tenderness to palpation in the setting of risk factors.
Infection:
- History: Age younger than 4 years, nighttime pain, history of tuberculosis exposure, recent infection.
- Physical Exam: Fever, wound in the spinal region, localized pain, tenderness, meningeal signs.
Inflammatory:
- History: Age younger than 4 years, morning stiffness lasting longer than 30 minutes and improving with activity or hot showers, joint pain.
- Physical Exam: Limited range of motion, localized pain, tenderness, joint swelling or warmth.
Fracture:
- History: Activities with repetitive lumbar hyperextension (e.g., sports like cheerleading, gymnastics, wrestling, football), trauma.
- Physical Exam: Tenderness to palpation over spinous process, positive Stork test, bruising or swelling.

Evaluation of Back Pain

In most cases, history and physical examination are sufficient to determine the cause of back pain. Early imaging in adults is often associated with worse outcomes, potentially leading to more invasive treatments with limited benefit. The same principle applies to pediatric populations. However, the presence of concerning signs or red flags necessitates diagnostic testing. In adults, back pain persisting beyond 6 weeks despite conservative management also warrants imaging. In children, imaging is recommended for persistent pain lasting more than 4 weeks.

Plain anteroposterior and lateral (APL) radiographs can detect bone pathology.

Figure: Lateral lumbar spine x-ray showing lytic lesions in L1 and L4 vertebral bodies due to multiple myeloma.

Magnetic resonance imaging (MRI) is indicated for evaluating soft tissue lesions, including nerves, intervertebral discs, and tendons. Both imaging modalities can detect signs of malignancy and inflammation, but MRI is preferred when soft tissue involvement is suspected. Bone scans can detect osteomyelitis, diskitis, and stress reactions but are generally inferior to MRI for evaluating these conditions.

In adolescents with MRI evidence of disc herniation, a computed tomogram (CT) may be needed to rule out apophyseal ring separation.

Electromyography (EMG) or nerve conduction studies are indicated for patients with prior spinal surgery who may be experiencing radiculopathy or plexopathy as a complication. Image-guided diagnostic injections can help confirm sacroiliac joint injury.

Laboratory tests may be necessary in certain back pain cases. Rheumatologic assays like HLA-B27, antinuclear antibody (ANA), rheumatoid factor (RF), and Lyme antibodies are typically not helpful as they are nonspecific for back pain. However, inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be useful in suspected inflammatory or infectious conditions. A complete blood count (CBC) and blood cultures may aid in diagnosing inflammatory, infectious, or malignant etiologies. Elevated lactate dehydrogenase (LDH) and uric acid levels can be found in conditions associated with rapid marrow turnover, such as leukemia.

Treatment and Management of Back Pain

Management approaches for back pain differ between adults and children. While many cases lack a specific identifiable cause, degenerative disease and musculoskeletal injuries are more common in adults, whereas overuse and muscle strain are more typical in children and adolescents. Rare conditions like malignancy and metabolic disorders also present differently across age groups. Therefore, treatments must be tailored to both the underlying condition and the patient’s age.

Management of Back Pain in Adults

For acute back pain in adults, serious conditions must be ruled out first. If no red flags are present, reassurance and symptomatic relief are key. First-line treatments are non-pharmacological:

Early return to normal activities, avoiding heavy labor initially.
Avoiding pain-provoking activities.
Patient education about back pain and self-management strategies.

Second-line options include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, opioids (used cautiously and for short durations), spinal manipulation, physical therapy, superficial heat application, and alternative treatments like acupuncture and massage. Patient education, tailored to individual circumstances, is crucial for preventing aggravation and recurrence. Follow-up after 2 weeks is recommended, with a focus on resuming normal routines if asymptomatic.

For acute radicular back pain in adults, NSAIDs, exercise, traction, and spinal manipulation may be considered. Diazepam and systemic steroids offer no additional benefit. Diagnostic tests and specialist referrals are necessary if serious conditions cannot be ruled out.

Chronic back pain management follows a similar approach. Ruling out serious conditions is the first step. For nonspecific chronic back pain, maintaining activity and avoiding aggravating factors are essential. Exercise therapy and cognitive behavioral therapy are considered first-line treatments. Second-line treatments include spinal manipulation, massage, acupuncture, yoga, stress reduction techniques, NSAIDs, selective norepinephrine reuptake inhibitors (SNRIs), and interdisciplinary rehabilitation programs.

The role of anticonvulsants like gabapentin and topiramate in chronic back pain management is uncertain. Transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo for chronic back pain.

Surgical referral is generally reserved for disabling low back pain lasting longer than 1 year, as recommended by the American Pain Society. However, evidence for commonly performed invasive procedures like epidural steroid injections and lumbar disc replacement is mixed.

Management of Back Pain in Children and Adolescents

Pediatric back pain treatments are less extensively studied. Activity modification, physical therapy, and NSAIDs are generally supported as first-line therapies. If serious pathology is identified, treatment follows the standard of care for that condition. Spondylolysis from repetitive spinal stress can be managed conservatively, similar to adults. However, young athletes might require surgical intervention in some cases. Symptoms persisting beyond 6 months of conservative therapy or Grade III or IV spondylolisthesis may warrant referral to a pediatric spine surgeon.

Scheuermann’s kyphosis with spinal curvature less than 60° can be managed conservatively with physical therapy and exercise. Bracing may be added for curvatures between 60° and 70°. Surgical correction is indicated for curvatures exceeding 75°, especially if conservative measures fail and skeletal maturity is reached. Surgical referral is also considered for spinal curvature of 20° or greater during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis.

Differential Diagnosis of Backache

The following sections outline the differential diagnosis of back pain in adults and children, including associated symptoms and physical examination findings. This list, while not exhaustive, covers the most common and serious conditions presenting with back pain.

Differential Diagnosis of Back Pain in Adults

Lumbosacral muscle strains and sprains: Typically caused by trauma or overuse. Pain worsens with movement, improves with rest. Range of motion is limited, muscles are tender to palpation. Common in automotive repair work involving heavy lifting and awkward postures.
Lumbar spondylosis (osteoarthritis of the spine): More common in individuals over 40. Hip pain may be present. Pain occurs with lower limb extension or rotation. Neurological exam is usually normal. Degenerative changes in the spine are common with aging and repetitive strain.
Disc herniation: Most commonly involves L4-S1 segments. May present with paresthesia, sensory changes, weakness, or reflex changes, depending on the severity and nerve root involved (radiculopathy). Can be exacerbated by lifting and bending.
Spondylolysis and spondylolisthesis: Caused by repetitive spinal stress, common in athletes and individuals with physically demanding jobs. May present with back pain radiating to the buttocks and posterior thighs. Neurological deficits may follow the L5 distribution.
Vertebral compression fracture: Localized back pain worsening with flexion. Point tenderness on palpation. May be acute (traumatic) or chronic (osteoporotic). Risk factors include steroid use, vitamin D deficiency, and osteoporosis. Consider in older adults or those with risk factors for osteoporosis.
Spinal stenosis: Characterized by leg sensory and motor weakness relieved by rest (neurogenic claudication). Neurological exam may be initially normal but progresses with increasing stenosis. Symptoms are often provoked by walking or prolonged standing.
Tumor: May be associated with unexplained weight loss, focal tenderness to palpation, or malignancy risk factors. Spinal tumors are often metastatic. Persistent night pain, unremitting pain, and systemic symptoms should raise suspicion.
Infection: Consider in patients with recent spinal surgery, IV drug use, or immunosuppression. Symptoms include fever, wound in the spinal region, localized pain, and tenderness. Common infections include vertebral osteomyelitis, diskitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess. Consider tuberculosis in individuals from endemic regions.
Fracture: May result from trauma, prolonged corticosteroid use, or osteoporosis. More common in patients over 70. Associated findings include contusions, abrasions, and tenderness to palpation over spinous processes.

Differential Diagnosis of Back Pain in Children and Adolescents

Tumor: May present with fever, malaise, weight loss, nighttime pain, and recent-onset scoliosis. Osteoid osteoma is a common tumor presenting with back pain often relieved by NSAIDs. Persistent and progressive pain, especially at night, is a red flag.
Infection: Associated symptoms include fever, malaise, weight loss, nighttime pain, and recent-onset scoliosis. Patients may refuse to walk. Common conditions are vertebral osteomyelitis, diskitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess. Epidural abscess should be considered if neurological deficits and radicular pain are also present.
Disc herniation and slipped apophysis: May present with acute back pain, radicular pain, and recent-onset scoliosis. Physical findings include a positive SLR test and pain on spinal forward flexion. More common in adolescents involved in sports.
Spondylolysis, spondylolisthesis, and posterior arch lesion: Acute-onset back pain presents with radicular pain. Hamstring tightness may be present. Physical findings include a positive SLR test and pain on spinal extension. Common in adolescent athletes, especially those involved in hyperextension activities.
Vertebral fracture: Trauma is the most common cause. Acute back pain may be associated with other injuries. Neurological deficits may be present. Stress fractures may present insidiously with progressive postural changes.
Muscle strain: Acute back pain typically associated with muscle tenderness without radiation. Usually self-limiting and related to activity.
Scheuermann’s kyphosis: Chronic back pain associated with rigid kyphosis. Postural deformity is a key feature.
Inflammatory spondyloarthropathies: Pertinent history includes chronic pain, morning stiffness lasting longer than 30 minutes, and sacroiliac joint tenderness. Consider in adolescents with persistent back pain and inflammatory symptoms.
Psychological disorder (conversion and somatization disorder): Persistent subjective pain with normal physical findings. Diagnosis of exclusion after ruling out organic causes.
Idiopathic scoliosis: Most commonly asymptomatic, with a positive Adam test. Back pain may be due to another cause if present in scoliosis patients. Scoliosis itself is usually not painful, but associated muscle imbalances can cause discomfort.

Prognosis of Back Pain

In adults, the prognosis of back pain varies depending on the underlying cause. Most nonspecific cases resolve without serious long-term issues. The effectiveness of conservative therapy and patient education highlights the subjective and often stress-related nature of pain. Factors associated with chronic, disabling back pain in patients with unidentifiable causes include prior back pain episodes, greater symptom intensity, depression, fear-avoidance behavior, and leg or widespread symptoms.

Social factors significantly influence prognosis. Low educational attainment, highly laborious jobs, poor compensation, and low job satisfaction are associated with worse outcomes, including higher disability rates. Lifestyle factors also play a role. A BMI over 25 and smoking are linked to persistent back pain.

Fewer studies have examined back pain prognosis in children. However, the etiology remains a key determinant of outcomes. Back pain caused by cancer is more likely to lead to disability than muscle strain. Nonspecific back pain in younger individuals can be exacerbated by behavioral comorbidities such as conduct problems, ADHD, passive coping, and fear-avoidance behavior.

Complications of Back Pain

Complications from back pain are determined by the underlying cause and can be both physical and social. Physical complications include chronic pain, deformity, and neurological deficits. Social complications encompass disability, reduced productivity, and increased absenteeism. Back pain is a leading cause of disability worldwide, highlighting its significant global impact.

Addressing back pain early and effectively is crucial to prevent chronicity and complications. Early mobilization and activity are beneficial, while sedentary behavior and obesity tend to worsen the prognosis.

Postoperative and Rehabilitation Care for Back Pain

Rehabilitation efforts are tailored to the underlying cause, patient comorbidities, and treatment goals. The McKenzie method is often beneficial for nonspecific chronic low back pain. Clinical Practice Guidelines for Physical Therapy recommend manual therapy, trunk strengthening, centralization techniques, directional preference exercises, and progressive endurance exercises for rehabilitation. Occupational therapy can assist with managing daily activities and using adaptive equipment. Assistive devices during patient transfers can reduce low back pain incidence in healthcare workers and are also applicable in other physically demanding professions.

Deterrence and Patient Education for Back Pain

Patient education for preventing back pain recurrence or aggravation should be personalized. Individuals in less physically demanding jobs should be encouraged to stay active and maintain a healthy weight (BMI < 25). Those in labor-intensive occupations should also maintain activity but avoid pain-provoking activities like heavy lifting and excessive back twisting. Proper lifting techniques, load lightening, and using lifting equipment are crucial.

Smoking avoidance is essential for all patients, as smoking increases back pain risk at any age. Intensive patient education sessions focusing on activity modification, staying active, and early return to normal activities have proven effective in facilitating return to work in adults.

While evidence is mixed regarding bookbag weight in pediatric back pain, the American Academy of Pediatrics recommends bookbags not exceed 10% to 20% of a child’s body weight.

Most back pain cases are self-limiting. However, all patients should be instructed to seek immediate medical attention for concerning signs like sudden sensory or motor weakness.

Pearls and Other Issues in Back Pain Management

Practice Pearls for Adult Back Pain Management:

History and physical exam are usually sufficient for diagnosis. Avoid routine early imaging in nonspecific acute low back pain.
Reassure patients that serious conditions are rare and encourage early return to activity.
First-line treatment is nonpharmacologic: heat, massage, acupuncture, spinal manipulation.
Pharmacologic options (second-line) include NSAIDs and muscle relaxants. Reserve opioids for severe, acute pain and use cautiously.
Acetaminophen is not effective for acute low back pain.
Antidepressants are not recommended for acute low back pain.
Consider McKenzie method for chronic low back pain.
Directional preference and centralization are useful prognostic tools.

Practice Pearls for Pediatric Back Pain Management:

Transient back pain with minor injury and no significant physical findings can be treated conservatively without further evaluation.
Abnormal physical findings, constant pain, nighttime pain, or radicular pain are indications for further evaluation.
Plain APL films are recommended as the first-line radiographic study.
Consider laboratory tests in the presence of clinical red flags.
Thoracic malignancy and infection are more likely in children than adults, especially those younger than 4 years.

Enhancing Healthcare Team Outcomes in Back Pain Management

A multidisciplinary approach involving various healthcare professionals is crucial for comprehensive back pain care, improved outcomes, and enhanced quality of life. The team typically includes primary care providers, nurses, pharmacists, nutritionists, physical therapists, occupational therapists, radiologists, and medical specialists as needed.

The primary care provider initiates the evaluation with a detailed history and physical examination, determines initial treatment, and assesses the need for further diagnostic testing and specialist referrals. Patient education, emphasizing smoking cessation and healthy weight maintenance, is a key role.

Nurses reinforce patient education, reiterate follow-up instructions, and provide evidence-based answers regarding nonpharmacologic therapy and continued physical activity. They ensure patient stability before discharge and coordinate care plans.

Pharmacists educate patients about prescribed medications, including benefits, risks, dosage instructions, and potential overdose risks. They clarify prescriptions with primary care providers as needed.

Nutritionists assist obese patients in making healthier dietary choices and maintaining a healthy weight, which is crucial for back pain management. Obesity medicine specialists may prescribe antiobesity medications as adjuncts to lifestyle modifications for significant weight loss.

Physical therapists prescribe appropriate strength and endurance exercises for back pain management and recurrence prevention. Physical therapy can effectively reduce opioid use in back pain patients. Occupational therapists provide ergonomic guidance and recommend assistive devices for managing back pain in work and home environments.

Radiologists interpret imaging findings and recommend further imaging if necessary.

Specialist referrals are made as needed. Pain specialists manage chronic pain with medication adjustments or pain-management procedures. Rheumatologists are consulted for back pain associated with inflammatory disease signs. Neurosurgery referral is indicated for severe radiculopathy or rapid neurological changes. Mental health therapists provide stress-coping techniques, cognitive behavioral therapy, and other treatments for back pain with a significant psychological component. Alternative medicine providers may also contribute to improved patient function.

Effective interprofessional communication prevents duplicated tests and conflicting treatments, ensuring coordinated and efficient patient care.

Review Questions

What are the common red flags for back pain that warrant further investigation?
Describe the differential diagnosis of back pain in adults and children.
What are the first-line and second-line treatment options for acute and chronic back pain?
Explain the role of different healthcare professionals in managing back pain.
What lifestyle modifications and preventive measures can help reduce the risk of back pain?

References

[List of references from the original article – already provided in the original text]

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