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Patient education: Low back pain in adults (Beyond the Basics)

Patient education: Low back pain in adults (Beyond the Basics)
Author:
Roger Chou, MD
Section Editor:
Joann G Elmore, MD, MPH
Deputy Editor:
Karen Law, MD, FACP
Literature review current through: Jan 2024.
This topic last updated: Sep 20, 2021.

OVERVIEW — Low back pain is very common. More than 80 percent of people have at least one episode of low back pain during their lifetime. Although back pain usually does not represent a serious medical problem and most often resolves on its own, it can be frustrating when pain interferes with daily life.

Certain factors seem to increase a person's risk of developing low back pain. These include smoking, obesity, older age, female sex, physically strenuous or sedentary work, job-related stress, job dissatisfaction, and mental health issues such as anxiety or depression.

Low back pain is often categorized as "acute" (lasting four weeks or less), "subacute" (lasting 4 to 12 weeks), or "chronic" (lasting more than 12 weeks). While most episodes of acute pain resolve quickly, some people do go on to have longer-term pain.

Back pain in children and adolescents is discussed separately. (See "Patient education: Back pain in children and adolescents (Beyond the Basics)".)

STRUCTURE OF THE BACK — To understand how pain can develop, it helps to understand the underlying anatomy. Your back is formed by bones, muscles, nerves, and other tissues that work together to help you stand and bend (figure 1). The bones of the back are called vertebrae, which together form the spinal column. The spinal column protects the spinal cord, the part of the central nervous system that controls your ability to feel and move.

The vertebrae are stacked one on top of another. The spinal cord passes through openings in the back of the vertebrae, and small nerves (called nerve roots) exit from the spinal cord and pass through spaces on the sides of the vertebrae. The spinal column extends below the base of the spinal cord. The nerve roots that run to the lower back and legs are collectively called the cauda equina.

Between each stacked pair of vertebrae in the spinal column is a disc composed of a tough outer tissue and a gel-like inner pulp. These discs protect the bones, acting like cushions or shock absorbers. The vertebrae are held together by ligaments and tendons, allowing the vertebrae to move together as the spinal column bends forwards, backwards, and side to side.

There are four main regions of the back; the cervical (C), thoracic (T), lumbar (L), and sacral (S) regions (figure 2).

The seven cervical vertebrae are located in the neck

The 12 thoracic vertebrae are located in the upper back

The five lumbar vertebrae are located in the lower back

The sacrum and coccyx are fused bones, found at the base of the spinal column

The vertebrae are numbered from top to bottom. As an example, the top (uppermost) lumbar vertebra is called the L1 vertebra. Low back pain occurs in the area of the lumbar and sacral vertebrae, most commonly at L4, L5, and S1.

CAUSES — Many different things can cause low back pain. Most of the time there is no specific cause, but, rarely, pain can be related to a disease or disorder.

Nonspecific back pain — Most people (more than 85 percent) have what doctors call "nonspecific" low back pain, which means that the pain is not clearly caused by a specific disease, abnormality, or serious injury of the spine. People sometimes refer to "throwing out" their back, meaning they had sudden-onset pain following physical activity (such as lifting a heavy object, shoveling, or bending). This type of pain most often represents a strain in one or more of the muscles in the lower back, and it can be severe.

While it can be frustrating to have pain with no identifiable cause, it may help to know that this type of back pain typically improves on its own within a few weeks, and there are things you can do to feel better in the meantime, such as applying heat and avoiding bedrest. Getting back to being active as soon as you feel able can help speed your recovery. (See 'Acute low back pain treatment' below.)

Serious potential causes — Rarely, back pain is caused by a potentially serious spinal condition, such as an infection, tumor, or a disorder called "cauda equina syndrome," which causes leg weakness and bowel or bladder dysfunction as well as back pain. Other potential causes include vertebral (spinal) compression fractures, in which one or more vertebrae become fractured as a result of weakening and thinning of the bones due to osteoporosis.

People with these problems usually have other risk factors or symptoms in addition to low back pain.

Less serious potential causes — Sometimes, low back pain is caused by specific, less serious conditions, including physical changes due to normal aging. Some of these causes are discussed below.

Degenerative disc disease — Over time, normal wear and tear can lead to degenerative disc "disease" (breakdown of the spinal discs), with the development of small cracks and tears and/or loss of fluid in the discs. This can lead to changes in the neighboring spinal vertebrae, including the formation of bone spurs (areas of bony overgrowth). Calling this condition a "disease" is somewhat misleading because these changes occur with normal aging. While the changes in the discs can cause back pain, there are many older people with degenerative disc disease who have no symptoms.

Bulging and herniated discs — Too much wear and tear on spinal discs can lead to the bulging of a disc, in which the outer covering is weakened and the disc protrudes. Many people have bulging discs seen on imaging tests (computed tomography [CT] scan and magnetic resonance imaging [MRI]) but do not have back pain. However, some people may develop sciatica (pain that extends down the back of the leg) if the bulging disc presses on a nerve (figure 3). (See 'Sciatica' below.)

This wear and tear can less commonly lead to herniation of a disc, in which the outer covering becomes weakened or torn and the soft inner tissue is pushed out. People often refer to this as a "slipped disc." Herniated discs can cause leg pain or weakness if the disc presses on a nerve root. However, herniated discs are also seen on imaging tests (CT scan and MRI) in people without back pain. Herniated discs usually heal over time because the body breaks down the excess disc material, relieving pressure or irritation on the nerve.

Osteoarthritis — Osteoarthritis can affect the joints that connect the vertebrae to one another, called the facet joints. This condition, known as facet joint arthropathy, can lead to bone spurs around the joint and may cause low back pain. However, like degenerative disc disease, facet joint arthropathy is very common with aging and many people with this condition have no symptoms.

Spondylolisthesis — Spondylolisthesis is a condition in which one of the vertebrae of the lower spine "slips" forward in relation to another. Spondylolisthesis is usually caused by stress on the joints of the lower back and may be associated with facet joint arthropathy. Although this condition can cause low back pain and sciatica, it may cause no symptoms at all.

Lumbar spinal stenosis — Spinal stenosis is a condition in which the vertebral canal (the open space inside the vertebrae) is narrowed. This is often caused by bone spurs, which can occur in older people with osteoarthritis (see 'Osteoarthritis' above). Some people with spinal stenosis have no symptoms, while others experience pain in the lower legs with walking; this is known as neurogenic claudication. (See 'Neurogenic claudication' below.)

Ankylosing spondylitis — In younger people, low back pain may be associated with an inflammatory condition called ankylosing spondylitis. People with this condition often have back stiffness in the morning and pain that improves with activity. Over time, if untreated, ankylosing spondylitis may result in the bones in the spine becoming fused together, reducing range of motion. (See "Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)".)

Occupational back pain — Sometimes back pain is related to occupational factors. These can include poor posture while sitting or standing at work, sitting or standing for long periods of time, driving long distances, improper lifting techniques, frequent lifting, and lifting excessively heavy loads. Low back pain is as common among workers who sit for prolonged periods as in people whose jobs require heavy lifting.

RELATED TERMINOLOGY — Low back pain can feel different to different people and may be associated with other features or symptoms depending on the cause. Below are some commonly used terms related to back pain.

Radiculopathy — Radiculopathy may accompany low back pain; it occurs when a nerve root in the spine is irritated by something pressing on it (a protruding disc, arthritis of the spine, or even a muscle in spasm). Symptoms of radiculopathy include radiating pain, numbness, tingling, or muscle weakness in the specific area related to the affected nerve root, usually the lower leg.

Sciatica — Sciatica is a type of radiculopathy; it occurs when one of the five spinal nerve roots, which are branches of the sciatic nerve, is irritated. The pain is typically sharp or burning and extends down the back or side of the thigh and may reach as far as the foot or ankle. You may also feel numbness or tingling. Occasionally, the sciatica may also be associated with muscle weakness in the leg or the foot. If a disc is herniated, sciatic pain often increases with coughing, sneezing, or bearing down.

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 (see 'Lumbar spinal stenosis' above). 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 (eg, when standing or walking) and gets better when flexing the spine by sitting, stooping, or leaning forward, even while walking.

IMAGING TESTS — The majority of people with low back pain improve within several weeks and do not require imaging tests such as X-rays.

Imaging tests, including X-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI), may be recommended in certain situations; however, they are not routinely ordered for all people with low back pain. These tests come with their own risks and have no benefit for most people with low back pain.

X-rays — X-rays (radiographs) may be recommended in certain cases, such as people who have risk factors for or signs of cancer, vertebral compression fracture related to osteoporosis, or ankylosing spondylitis. X-rays expose the body to radiation, which is one of the reasons they are not routinely done unless a particular issue is suspected.

X-rays do not usually show enough detail to diagnose a herniated disc or spinal stenosis. Other common conditions, such as degenerative disc disease and facet joint arthropathy, may be seen on X-ray, but these are common problems that are also present in many people who do not have back pain. Because of this, and because finding X-ray evidence of these conditions does not change the immediate treatment approach, X-rays are typically not recommended to look for them.

CT and MRI — CT scans and MRI provide detailed images of the soft tissues and bony structures of the back. A CT or MRI is usually necessary to diagnose a bulging or herniated disc or spinal stenosis. One of these tests may be recommended if there are risk factors or signs of infection or cancer, if surgery is being considered, or if low back pain persists for more than four to six weeks and the cause is not clear.

Most people with low back pain do not require a CT or MRI. Disc and spine abnormalities are common even among people without low back pain. In fact, a herniated disc is seen on CT scan or MRI in 25 percent of people without low back pain. Finding an abnormality on an imaging test can lead to further testing and treatment that may not be helpful or necessary. CT scans also expose the body to radiation (even more so than X-rays). MRI is based on magnetic fields and does not require radiation.

ACUTE LOW BACK PAIN TREATMENT — Unless acute low back pain is caused by a serious medical condition (which is uncommon), it typically resolves fairly quickly, even if there is a bulging or herniated disc.

Still, low back pain can make it hard to do your usual activities, and it can be frustrating to feel like you just have to wait for it to get better. Below are some simple things you can do that may help relieve your pain.

Remaining active — Many people are afraid that they will hurt their back further or delay recovery by remaining active. However, remaining active, to the extent that you are able, is one of the best things you can do for your back.

If you have severe pain, you may need to rest your back for a day or so. It may be most comfortable to lie on your back with a pillow under your knees and your head and shoulders elevated. For sleeping, you may want to lie on your side with your upper knee bent and a pillow between your knees. However, 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.

While you should avoid strenuous activities and sports while you are in pain, it is fine to continue doing regular day-to-day activities and light exercises, such as walking. If certain activities cause your back to hurt too much, try something else instead.

Heat — Using a heating pad or heated wrap can help with low back pain during the first few weeks. It is not clear if cold helps as well, but some people may find that it relieves pain temporarily.

Modifications at 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 and heavy lifting. If your job does not allow you to sit or stand comfortably, you may need to take some time off work while you recover. 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 — You can try taking an over-the-counter medication to help relieve pain. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (sample brand names: Advil, Motrin) and naproxen (brand name: Aleve), may work better than acetaminophen (brand name: Tylenol) for low back pain.

If you do take pain medication, it may be more effective to take a dose on a regular basis for three to five days, rather than using the medication only when your pain becomes unbearable. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Muscle relaxants (eg, cyclobenzaprine [brand name: Flexeril]) are prescription medications; while these may help relieve back pain, they can cause drowsiness and are probably no better than ibuprofen in relieving pain. Your health care provider can talk to you about whether muscle relaxants might help in your situation. They may be helpful before bedtime when used for a short time, ie, a week or two. People who need to be alert, such as while driving or operating machinery, should not use muscle relaxants.

Opioids (drugs derived from morphine) are not recommended for most people with back pain. In rare situations, a health care provider might prescribe them for a few days if a person has severe pain that is not responding to other treatments, but they are generally not much more effective than NSAIDs. In addition, opioids have a relatively high risk of side effects and the potential to cause harm, including the risk of dependency and abuse.

Exercise — Starting a new exercise program immediately after a new episode of low back pain will not speed recovery from the acute episode. However, there is evidence that exercise is beneficial in people with chronic back pain. (See 'Chronic low back pain treatment' below.)

Spinal manipulation — "Spinal manipulation" is a technique sometimes used by chiropractors, physical therapists, osteopaths, massage therapists, and others to relieve back pain. It involves moving the joints of the spine beyond the normal range of motion. Studies suggest that spinal manipulation may provide modest pain relief and improved function, and it generally appears to be safe if performed by an experienced professional. If you are interested in trying this approach, talk with your health care provider about how to integrate it into your treatment plan.

Acupuncture — Acupuncture involves inserting very fine needles into specific points, as determined by traditional Chinese maps of the body's flow of energy. There is not consistent evidence that acupuncture is effective for people with acute low back pain; however, some people find it helpful.

Massage — There is no evidence that massage is effective in treating acute low back pain. However, you may find that it is generally relaxing and helps you feel better temporarily.

Psychological therapy — In some cases, mental health issues can contribute to low back pain. In addition, some people find it difficult to cope with low back pain. Psychological therapy has mostly been studied in the context of treating longer-term (chronic) back pain; however, it may be beneficial for some people with acute pain as well. (See 'Chronic low back pain treatment' below.)

Other treatments — You may have heard of other treatments that claim to relieve back pain. Unfortunately, most of these have not been proven to work or are only effective in specific situations. Examples include:

Injections – Some clinicians recommend injections of a local anesthetic (numbing medication) into the soft tissues of the back, although it is not clear if these injections are effective. The areas targeted by these injections are called "trigger points." Trigger-point injections may be of benefit in some people with chronic back pain, but they are typically not recommended for treating acute pain.

Injections of a glucocorticoid (steroid) medication are sometimes recommended for people with chronic low back pain with sciatica or radiculopathy (see 'Related terminology' above). The injection is given into the epidural space, which is located below the spinal cord. Epidural glucocorticoid injections do appear to improve pain slightly at two and six weeks after the injection, but not at 3, 6, or 12 months after the injection. There is no evidence that epidural steroid injections are helpful for people with back pain without sciatica.

Corsets and braces – While wearable supportive garments may claim to help relieve or prevent low back pain, these are typically not effective.

Traction – Traction involves the use of weights to realign or pull the spinal column into alignment. Clinical studies have shown no benefit from traction in the treatment of acute back pain.

Switching to a firmer mattress – People often wonder if sleeping on a firmer mattress can help prevent or treat low back pain. Small studies have suggested that using a less firm mattress may actually be more likely to relieve pain; however, there is not enough evidence to support switching to a specific type of sleeping surface for this reason.

Methods involving energy or electricity – Other interventions include ultrasound, interferential therapy, shortwave diathermy, transcutaneous electrical nerve stimulation, and low-level laser therapy, all of which involve applying energy to the skin's surface. None of these interventions have been proven to be effective, particularly during the first four to six weeks of an episode of back pain.

CHRONIC LOW BACK PAIN TREATMENT — While most people recover completely from an episode of acute low back pain, some people do go on to have longer-term pain. Chronic pain is typically defined as pain lasting 12 weeks or longer. Back pain that lasts between 4 and 12 weeks is called "subacute"; the treatment approach for subacute back pain aims to decrease the risk that your pain will progress to the chronic stage.

The treatments for subacute and chronic low back pain are similar to those for acute pain. While there is limited evidence for many of these, you may find that a combination of approaches helps.

Self care — This involves being aware of your pain level and modifying your activities as needed without completely restricting movement. While it can be tempting to avoid physical activity, and you may need to rest when symptoms are severe, staying active (to the extent possible) is the best thing you can do to improve your pain over time. Applying heat and doing gentle stretches can also help, as can trying relaxation exercises.

Movement-based therapy — If you have had back pain for more than four to six weeks, or there are signs that your back pain is not improving, your health care provider may recommend working with a physical therapist to develop an individualized exercise program. This may involve stretching, flexion and extension exercises, strengthening, aerobic activity, general overall fitness, or some combination of these components. A physical therapist may directly supervise exercise sessions or teach you to follow your program at home.

Exercise can help to increase back flexibility and strengthen the muscles that support the back. Recommended activities include those that involve strengthening and stretching, such as walking, swimming, use of a stationary bicycle, and low-impact aerobics. Exercises to strengthen the muscles in and around the lower back are helpful. If you have frequent episodes of low back pain, doing these exercises regularly can help prevent new episodes.

Some people find activities with a mind-body focus, such as Tai Chi and yoga, to be beneficial. Whatever exercise program you follow, the goal is not only to improve pain but to help you regain function and be able to do your normal daily activities. In addition, staying active can help reduce stress and anxiety.

Psychological and mind-body therapies — People who have a lot of fear about moving because of their back pain, feel hopeless about improving, have depression or anxiety, or are otherwise having trouble coping with their back pain can benefit from something called cognitive behavioral therapy (CBT). CBT involves learning about your condition (including addressing any misconceptions and fears that you may have about your low back pain), learning how to develop a more positive way of thinking, and setting activity goals and working toward those goals. CBT techniques may be performed by a psychologist, physical therapist, or clinician.

Some people also find that something called "mindfulness-based stress reduction" helps. This involves attending a group program to practice relaxation and meditation techniques with someone trained in this approach.

It may help to consider whether any psychological factors might be affecting your physical wellbeing. If you are depressed or suffering from stress or anxiety, your health care provider can help you and talk to you about your options. Addressing psychological stressors can improve your chances of recovering from low back pain. (See "Patient education: Depression in adults (Beyond the Basics)".)

Short-term symptom relief — While evidence is limited, some people find that one or more of the following approaches help with pain (even if only temporarily):

Spinal manipulation (see 'Spinal manipulation' above)

Acupuncture (see 'Acupuncture' above)

Massage (see 'Massage' above)

Pain medications (see 'Pain medications' above)

Temporary relief of symptoms can make it easier to participate in exercise and psychological or mind-body therapies, which are more effective in the long term. (See 'Movement-based therapy' above and 'Psychological and mind-body therapies' above.)

SURGERY — Only a small minority of people with low back pain will require surgery. Surgery is necessary if there is evidence of cauda equina syndrome (problems with the nerves at the base of the spinal cord), another serious back condition like a tumor or infection, or severe weakness due to spinal stenosis or compression of a nerve root; however, these situations are not common.

Surgery may also be considered for people with persistent radiculopathy due to herniated disc or spinal stenosis that has not responded to other (nonsurgical) therapies. There is controversy about whether surgery is beneficial for people with degenerative disc disease alone.

Your health care provider may refer you to an orthopedic surgeon or neurosurgeon if you have:

Increasing neurologic problems (eg, weakness)

Loss of sensation (numbness) or bladder and bowel problems

No improvement after four to six weeks of nonsurgical management, with persistent and severe sciatica and evidence of nerve root involvement

WHEN TO SEEK HELP — Most of the time, an episode of back pain will get better on its own and does not require extensive testing or treatment. Some people with low back pain should be evaluated and managed by a primary care provider. If low back pain is caused by a serious condition, a neurosurgeon or orthopedist who specializes in back disorders is usually recommended.

It's a good idea to see your health care provider if you have:

New back pain if you are 70 years or older.

Pain that does not go away, even at night or when lying down.

Weakness in one or both legs or problems with bladder, bowel, or sexual function – These can be signs of cauda equina syndrome, and they result from compression of the nerve bundle at the base of the spine. These symptoms should be evaluated as soon as possible.

Back pain accompanied by unexplained fever or weight loss.

Back pain with a history of cancer, a weakened immune system, osteoporosis, or the use of corticosteroids (eg, prednisone) for a prolonged period of time.

Back pain that is a result of falling or an accident, especially if you are older than 50 years.

Pain spreading into the lower leg, particularly if accompanied by weakness of the leg.

Back pain that does not get better within four weeks.

If you have an episode of back pain that resolves, it is generally not necessary to consult your health care provide unless you have specific questions or concerns.

PREVENTION — Recurrence is common after an initial episode of acute low back pain. The best way to lower your risk of having another episode is to stay active. This can involve aerobic exercise that improves cardiovascular fitness (such as walking, jogging, or swimming) as well as specific exercises to strengthen the muscles in your hips and torso. The abdominal muscles are particularly important in supporting the lower back and preventing back pain. There is no one specific exercise routine that is best for preventing back pain; it is best to try to find activities that you enjoy doing and that target the different muscles in and around your low back.

It can also help to:

Use proper form when lifting heavy objects – People with low back pain should learn the right way to bend and lift. When lifting a heavy object, keep your knees bent and tighten your abdominal muscles to avoid straining the weaker muscles in the lower back (picture 1).

Take regular breaks – If you sit or stand for long periods, it's a good idea change positions often and use a chair with appropriate support for your 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 can also help prevent pain due to prolonged sitting or standing. If you have to stand in one place for long periods of time, you can try placing a block of wood on the floor, stepping up and down every few minutes.

WHERE TO GET MORE INFORMATION — Your health care practitioner is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Low back pain in adults (The Basics)
Patient education: Spinal stenosis (The Basics)
Patient education: Vertebral compression fracture (The Basics)
Patient education: Herniated disc (The Basics)
Patient education: Scoliosis (The Basics)
Patient education: Muscle strain (The Basics)
Patient education: Cauda equina syndrome (The Basics)
Patient education: Do I need an X-ray (or other test) for low back pain? (The Basics)
Patient education: Radiculopathy of the neck and back (including sciatica) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Back pain in children and adolescents (Beyond the Basics)
Patient education: Chronic pain (The Basics)
Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of the clinical uses of acupuncture
Evaluation of low back pain in adults
Exercise-based therapy for low back pain
Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis
Lumbar spinal stenosis: Treatment and prognosis
Maternal adaptations to pregnancy: Musculoskeletal changes and pain
Occupational low back pain: Evaluation and management
Spinal manipulation in the treatment of musculoskeletal pain
Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment
Subacute and chronic low back pain: Nonsurgical interventional treatment
Subacute and chronic low back pain: Surgical treatment
Treatment of acute low back pain

The following organizations also provide reliable health information.

National Library of Medicine

National Institute of Neurological Disorders and Stroke

American Academy of Orthopaedic Surgeons

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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