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Pain & Symptoms

Low back pain (LBP) and chronic back disorders: epidemiology, multifactorial etiology, and the impact of biological and psychosocial drivers on disability.

Overview

In the management of pelvic girdle pain, persistency and duration of symptoms, alongside widespread pain, serve as the strongest predictors of poor long-term outcomes [1]. For chronic low back pain, high-quality trials with long-term follow-up are recommended to rigorously evaluate disability, quality of life, and pain outcomes associated with transcutaneous vagus nerve stimulation [2]. Approaches to primary outcome assessment in back pain require re-assessment to ensure validity [48].

Diagnostic and therapeutic strategies must be tailored to specific patient presentations. Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, though its validity is controversial and postdiskography surgical outcomes are inconsistent [6]. Management plans that efficiently address back pain alongside coexistent sites may maximize functional benefits, address patient life goals, and mitigate disability [46]. For neck-shoulder pain, tailored treatment guided by clinical assessments and standardized functional tests is hypothesized to yield superior short, intermediate, and long-term effects compared to non-tailored or usual care [4]. In elderly patients with musculoskeletal injury, proxy-reported patient-reported outcomes may better characterize functional impairment and pain while decreasing selection bias in outcomes research [54].

Postoperative pain management requires strict adherence to evidence-based guidelines to minimize subjectivity and prevent overtreatment or undertreatment [19]. The exclusive use of pain scores should be limited to prevent complications [5], with a Patient-Acceptable Symptom State (PASS) threshold for the Numeric Rating Scale (NRS) established at 2.1 for postoperative non–shoulder hand and upper-extremity populations [23]. During joint and soft tissue injections, most patients experience usually mild procedural pain, yet procedural pain management is uncommonly provided by physicians [3].

Anatomy & Pathophysiology

Kinematics and Postural Dynamics

Global lumbar spine kinematics do not reflect regional lumbar spine kinematics [32], while kinematic MRI demonstrates dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation [63]. Four subgroups of lumbo-pelvic flexion kinematics exist with an unequal distribution among people with and without a history of persistent low back pain [62], and there is an association between hip-pelvic kinematics and future low back pain [49]. The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties [81], whereas pain reduction did not alter lumbar range of motion, angular velocity, angular acceleration, or movement irregularity [89].

Assessment Modalities

Diagnostic Tools: Currently available wearable devices are capable of assessing spinal posture with good accuracy in the clinical setting [64], rasterstereography is a valuable tool for the dynamic evaluation of spinal posture and pelvic position and can quantify motion in the spine [82], and photographs provide valid and reliable indicators of the position of the underlying spine in sitting [94]. Early screening for incorrect postures and angle of trunk rotation could be an effective strategy to predict the severity of adolescent idiopathic scoliosis [83], and this is the first comprehensive systematic review of diagnostic accuracy studies evaluating clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine [84].

Morphology and Biomechanical Stress

Spinal morphology and its correction appear to influence the intensity and location of back pain in adolescent idiopathic scoliosis, although balance did not influence pain severity [80]. In type I thoracolumbar disc herniation, disc degeneration was accelerated by regional kyphosis, while in type II, excessive mechanical stress was directly loaded at the thoracolumbar apex [87]. Finite element analysis indicates that cervical vertebrae after percutaneous posterior endoscopic cervical discectomy (PPECD) treatment show good biomechanical performance and stability [79]. Large lumbar spine fusion or high-grade lumbosacral transitional vertebrae (LSTV) is probably the most deleterious to spinal mechanics and outcomes after hip arthroscopy [93], whereas low-grade LSTV with maintained spinopelvic motion is perhaps not critical for outcomes following hip arthroscopy [93]. Dentists exhibit typical patterns of postures during tasks essential to dental treatment, with higher angular values in the cervical and thoracic spine during treatment compared to other dental tasks [96].

Classification

Quebec Task Force Classification: This system categorizes neck pain into three distinct clinical syndromes: axial neck pain, cervical radiculopathy, and cervical myelopathy [12]. Each of these syndromes possesses distinct pathophysiological mechanisms and management strategies [12]. The classification identifies different low back pain subgroups at baseline [65] and demonstrates a consistent ranking of the four Quebec Task Force categories with respect to outcomes [65]. Furthermore, baseline and outcome differences exist between neck pain subgroups classified using this system [44].

Multidimensional Pain Inventory (MPI): The MPI subgroup classification is substantially stable in chronic back pain patients when compared to other diagnostic groups and other examiner-based subgroup classification systems [30]. MPI subgroup classification showed significant differences in score changes for pain, mental health, and coping [71].

Latent Class Analysis: A two-stage approach using latent class analysis is preferable to a single-stage approach for identifying subgroups of patients with low back pain because it yields more distinct and clinically meaningful subgroups [61]. The identified latent classes provide unique information on pain location and intensity in emerging adults [66].

STarT-Back Risk Schema: A risk classification schema using recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute low back pain had limited ability to identify persons who progressed to chronic pain [51].

Other Considerations: Numerous classification systems exist for patients with leg pain, but a minority focus specifically on distinguishing between different presentations of leg pain [7]. Diagnosis and treatment of Complex Regional Pain Syndrome are challenging and often require a multidisciplinary approach [11]. Aggregation of different locations of pain or different intensities of pain into one binary classification of low back pain may result in loss of information useful in prevention or treatment [14]. Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement [67], and the heterogeneity of patients with low back pain is more complex than that which can be explained by leg pain patterns alone [67]. Differences in characteristics of nonspecific low back pain between elderly and young patients were successfully detected using a new detailed Visual Analogue Scale scoring system [72]. Pain medication use varied with pain severity in older Irish adults with osteoarthritis [74], and different medication types reported by these patients broadly aligned with OA guidelines [74].

Clinical Presentation

Persistency and duration of pain symptoms, alongside widespread pain, appear to be the strongest predictors of poor long-term outcome [1]. Aggregating different locations or intensities of pain into a single binary classification for low back pain may result in loss of information, though such loss could potentially be useful in prevention or treatment [14]. The presence of comorbidities is associated with poorer care for low back pain [41].

Axial neck pain, cervical radiculopathy, and cervical myelopathy represent the three clinical syndromes of degenerative cervical spondylosis, each possessing distinct pathophysiological mechanisms and management strategies [12]. Numerous classification systems exist for patients with leg pain, yet a minority focus specifically on distinguishing between different presentations [7]. Diagnosing sacroiliac joint–mediated pain is difficult because presenting complaints mimic other causes of back pain; controlled analgesic injections serve as the most important diagnostic tool, though no published prospective data compare treatment modality efficacy [17]. Most patients with lumbopelvic pain can have a tissue source of pain identified using available reference standards [16].

Early diagnosis of Cauda Equina Syndrome is often challenging due to subtle initial signs and symptoms [37]. Pain serves as a critical warning sign for impending complications such as compartment syndrome; masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes [29]. Diagnosis and treatment of Complex Regional Pain Syndrome are challenging and often require a multidisciplinary approach [11].

Appropriate clinical workup leads to earlier diagnosis and management of back pain in children and adolescents while avoiding unnecessary cost [8]. A careful history and physical examination, supported by a working knowledge of the differential diagnosis, should allow clinicians to treat young patients with back pain safely and efficiently [10]. Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments [33].

Most patients experience usually mild procedural pain during joint and soft tissue injections, yet procedural pain management is uncommonly provided by physicians during these procedures [3]. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [5]. Pain in the thigh following total hip replacement with a porous-coated anatomic prosthesis for osteoarthrosis continues to be a concern and may well indicate a poor prognosis [38].

Investigations

Plain radiography: Associations between x-ray features of lumbar disc degeneration and the severity of disability or pain intensity remain inconclusive [68]. While radiographs are standard, diagnostic delay may occur in cases of anaerobic spondylodiscitis if patients present with back pain but no fever, leading to atypical spinal radiographs [75]. Extensive diagnostic studies are not necessary to evaluate every patient presenting with scoliosis and back pain [97].

MRI: Findings on magnetic resonance scans of the lumbar spine are not predictive of the development or duration of low-back pain in asymptomatic subjects [52]. MRI abnormalities examined are not major predictors of outcome in patients with low back pain [70], and few MRI findings show large magnitude associations with symptom outcomes even with specific definitions [85]. Although single MRI findings in asymptomatic people are common and often weakly associated with low back pain, subgroups with multiple and severe lumbar MRI findings demonstrate a stronger association than those with milder degeneration [86]. Early MRI is associated with increased length of disability in patients with acute low back pain without red flags [77]. However, imaging techniques, especially MRI, are invaluable for identifying infectious spondylitis, assessing its extent, and guiding treatment [78]. MRI is not always definitive for early stage sacral stress fractures, necessitating repeat imaging [98]. Predictive MRI signs have been identified in patients with symptomatic acromioclavicular osteoarthritis [91], and clinicians should be aware of common anatomic findings on MRI when considering diagnostic and treatment planning for individuals with unilateral shoulder pain [88].

CT: SPECT/CT bone scintigraphy is useful for identifying referred pain sources in young athletes with low back pain [90]. This modality allows for avoiding unnecessary irradiation by limiting CT acquisition to cases with abnormal SPECT findings [90].

Bone scan: SPECT/CT bone scintigraphy serves as a diagnostic tool for identifying referred pain sources in young athletes with low back pain [90].

Aspiration: Controlled analgesic injections are the most important diagnostic tool for diagnosing sacroiliac joint–mediated pain [17]. No published prospective data compare the efficacy of treatment modalities for sacroiliac joint–mediated pain [17]. Diagnosing sacroiliac joint–mediated pain is difficult because presenting complaints are similar to other causes of back pain [17].

Laboratory: A diagnostic algorithm exists that uses only one laboratory test and no advanced imaging [95].

Other Considerations: Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes [6]. Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost [8]. Physical examination tests are not very helpful in clarifying the cause of radicular pain and are therefore inaccurate for guidance in the diagnostic workup of chronic lumbar radiculopathy [92]. Severe pain with limited range of motion is a reliable clinical sign [95].

Treatment

Non-Operative

Conservative management serves as the primary intervention for numerous spinal and musculoskeletal conditions. Initial treatment for atlantoaxial osteoarthritis is conservative, with as many as two-thirds of patients improving, while surgery is indicated for incapacitating pain recalcitrant to nonoperative management [36]. Conservative treatment should be considered as a first-line option for spontaneous regression of large-sized lumbar facet synovial cysts if symptoms can be controlled to prevent unnecessary surgery [58]. Treatment for back pain, disk disease, spondylolysis, and spondylolisthesis is typically driven by symptomatology, with most patients responding to physical therapy, rest, and/or bracing, while surgical treatment may be considered if nonsurgical measures fail [69]. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, and direct surgical repair can yield high rates of pain relief in recalcitrant cases [73]. A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular peripheral neuropathic pain [45]. A multidisciplinary pain management program for patients with chronic low back pain could be an effective treatment to reduce pain intensity and improve on self-reported quality of life, although a future randomized clinical trial is needed to determine its effectiveness [40]. Tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests is hypothesized to have better short, intermediate, and long-term effects on pain and function than non-tailored treatment or treatment-as-usual [4].

Operative

Indications: Surgical intervention is reserved for cases where conservative measures fail or specific structural pathologies exist. Operative management of herniated lumbar disc resulted in greater symptom relief and functional improvement compared to nonoperative management [55]. Operative intervention for paralumbar compartment syndrome offers positive outcomes and symptom relief compared to non-operative treatment [47]. If nonoperative treatment fails to relieve symptoms in coracoid impingement, surgical decompression can be offered as an option [50]. Surgery is indicated for incapacitating pain recalcitrant to nonoperative management in atlantoaxial osteoarthritis [36]. Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes [6].

Pain Management: Postoperative pain strategies must balance efficacy with safety and patient-specific factors. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [5]. Establishing more uniform, evidence-based guidelines for postoperative pain management may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations [19]. Better counseling and innovative nonopioid pain management protocols are needed based on patient perceptions regarding pain control after shoulder surgery [53]. Most patients experience usually mild procedural pain during joint and soft tissue injections, and procedural pain management is uncommonly provided by physicians [3]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes for transcutaneous vagus nerve stimulation in chronic low back pain [2].

Other Considerations: Patient selection and prognostic factors significantly influence surgical outcomes and pain trajectories. Persistency and/or duration of pain symptoms as well as widespread pain appear to be the strongest predictors of poor long-term outcome [1]. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best in a randomized controlled trial of dose–response of spinal manipulation for chronic low back pain [18]. A value of 2.1 represents the Patient-Acceptable Symptom State (PASS) threshold for the Numeric Rating Scale (NRS) pain score in a postoperative non–shoulder hand and upper-extremity population [23]. A 1.4-cm improvement on a 10-cm pain visual analog scale indicates patients have achieved a clinically important improvement in their pain levels after treatment for rotator cuff disease [42]. Greater self-efficacy was the best determinant of satisfaction with pain relief after fracture surgery [31]. Targeting self-efficacy contributes to fast improvement in functional status for selected and motivated patients with persistent chronic low back pain [34]. Patients with longer pain duration indicated greater self-efficacy, and patients with higher pain disability and depression exhibited lower self-efficacy in intractable chronic pain [39]. Pain self-efficacy did not moderate the relationship between treatment and outcome in people with shoulder pain receiving manual therapy, acupuncture, or electrotherapy [28]. Age and pain sensation should be considered as important parameters for the recommendation for total shoulder arthroplasty (TSA) in patients with shoulder osteoarthritis [60]. Clinical outcomes for Cotrel-dubousset instrumentation in adolescent idiopathic scoliosis were favorable, with high patient satisfaction and low rates of pain interfering with daily activities [35]. Using available reference standards, most patients with lumbopelvic pain can have a tissue source of pain identified [16]. It is still not known whether early surgery or active physiological management offers the better chance for recovery in acute spinal cord injury due to the lack of properly conducted trials comparing surgery versus active conservative care [76]. Pain relief from cyclic bisphosphonate therapy occurs immediately following infusion, with functional improvements observed 4 weeks later in children with osteogenesis imperfecta [43].

Complications

Stiffness / Arthrofibrosis: Adhesive capsulitis follows a natural history of gradual resolution over 1 to 3 years, yet persistent limitation occurs in 50% to 60% of patients [26]. Pain at baseline serves as the strongest predictor for pain at follow-up in both neck and upper extremity regions [22].

Nerve palsy: Up to half of patients continue to report painful neuropathic symptoms at 15 months after total knee arthroplasty [21]. In cauda equina syndrome, persistent severe back pain and ongoing autonomic dysfunction were frequently reported at a mean follow-up of five years [13].

Other Considerations: Persistency and/or duration of pain symptoms, as well as widespread pain, appear to be the strongest predictors of poor long-term outcome [1]. Pain at baseline was the strongest predictor for pain at follow-up in both neck and upper extremity regions [22]. Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts [9]. Most patients experience usually mild procedural pain during joint and soft tissue injections, yet procedural pain management is uncommonly provided by physicians for these procedures [3]. The exclusive use of pain scores in postoperative pain management should be limited to prevent complications [5]. Marines with a history of back pain are at risk of further back pain episodes [25]. Significant risk factors for developing low back pain include a previous history of low back pain and the presence of low back pain symptoms at the start of work [99]. Women were generally more likely to report pain than men in the lumbar, thoracic, or cervical regions, and pain was reported as more long-lasting in older groups [59]. The HIZ sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain [100]. Long-term sequelae and morbidity in acute hematogenous osteomyelitis in children are primarily due to delays in diagnosis and inadequate treatment [56]. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [101].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity initiation across the provided cohorts. However, short-term repeat assessment of pain was found to be superior to baseline scores or short-term change in predicting long-term disability improvement for low-back and shoulder pain [9]. In the context of spinal manipulation for chronic low back pain, pain collected shortly after the completion of a 6-week study intervention served as the strongest predictor of future pain [18].

Full activity (months): Timeframes for full activity return vary by pathology. Patients with intraspinal synovial cysts demonstrated complete resolution of sciatica within a follow-up period ranging from eighteen to twenty-five months [104]. Conversely, up to half of patients continued to report painful neuropathic symptoms at 15 months following total knee arthroplasty, though these symptoms did improve over time [21]. For adhesive capsulitis, the natural history involves gradual resolution over 1 to 3 years, yet persistent limitation occurs in 50% to 60% of patients [26]. Marines with a history of back pain remain at risk for further back pain episodes [25].

Complete recovery / outcome plateau (months): Persistent severe back pain and ongoing autonomic dysfunction were frequently reported at a mean follow-up of five years in patients with cauda equina syndrome [13]. Persistency and/or duration of pain symptoms, as well as widespread pain, appear to be the strongest predictors of poor long-term outcome [1]. Pain at baseline was the strongest predictor for pain at follow-up in both neck and upper extremity regions among sonographers [22]. Additionally, changes in motor control patterns in whiplash and chronic neck pain were more likely attributable to long-lasting pain rather than a history of neck trauma or current pain [27].

Rehabilitation protocol: Tailored treatment is hypothesized to yield better short, intermediate, and long-term effects on pain and function compared to non-tailored treatment or treatment-as-usual [4]. Percutaneous endoscopic lumbar discectomy (PELD) under local anesthesia yielded remarkable improvements in pain and disability across all symptom severity groups [20]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes for transcutaneous vagus nerve stimulation in chronic low back pain [2]. The VAS score (average pain during the past 4 weeks) was identified as a prognostic factor for neuropathic pain in patients with rotator cuff tears [103].

Functional milestones: Enrolment of low back pain patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design [24].

Key Evidence

  • [L2] Persistency and/or duration of pain symptoms as well as widespread pain appear to be the strongest predictors of poor long-term outcome. (10.1186/s12891-017-1760-5)
  • [L1] Therefore, high-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes. (10.1186/s12891-024-07569-w)
  • [L4] Most patients experience usually mild procedural pain and procedural pain management is uncommonly provided by physicians. (10.1186/1471-2474-11-16)
  • [L2] The authors hypothesize that tailored treatment will have better short, intermediate, and long-term effects on pain and function than non-tailored treatment or treatment-as-usual. (10.1186/1471-2474-13-75)
  • [L4] The exclusive use of pain scores in postoperative pain management should be limited to prevent complications. (10.1016/j.arthro.2006.11.002)
  • [L5] Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes. (10.5435/00124635-200601000-00008)
  • [L1] Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. (10.1186/s12891-016-1074-z)
  • [L5] Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost. (10.5435/jaaos-d-14-00130)
  • [L2] Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. (10.1186/s12891-017-1502-8)
  • [L5] A careful history and physical examination, along with a working knowledge of the differential diagnosis of pediatric back pain, should allow the clinician to treat young patients with back pain safely and efficiently. (10.5435/00124635-199703000-00002)
  • [L4] This review elucidates the recent advances in the knowledge of the aetiology, classification and treatment of Complex Regional Pain Syndrome, highlighting that diagnosis and treatment are challenging and often require a multidisciplinary approach. (10.1177/1753193412471021)
  • [L5] Symptoms are categorized into three clinical syndromes: axial neck pain, cervical radiculopathy, and cervical myelopathy, each with distinct pathophysiological mechanisms and management strategies. (10.2106/00004623-200706000-00026)
  • [L3] Persistent severe back pain and ongoing autonomic dysfunction were frequently reported at a mean follow-up of five years. (10.1302/0301-620x.103b9.bjj-2021-0094.r1)
  • [L4] Aggregation of different locations of pain or different intensities of pain into one binary classification of LBP may result in loss of information which may potentially be useful in prevention or treatment of LBP. (10.1186/1471-2474-15-283)
  • [L3] Using available reference standards, most patients can have a tissue source of pain identified. (10.1186/1471-2474-6-28)
  • [L5] Diagnosing sacroiliac joint–mediated pain is difficult because presenting complaints are similar to other causes of back pain; controlled analgesic injections are the most important diagnostic tool, while no published prospective data compare the efficacy of treatment modalities. (10.5435/jaaos-d-17-00132)
  • [L2] Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best. (10.1186/s12891-015-0632-0)
  • [L3] These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations. (10.1177/1558944721998020)
  • [L3] PELD under local anesthesia yielded remarkable improvements in pain and disability across all symptom severity groups, supporting its broader adoption with tailored risk stratification to enhance long-term success. (10.1186/s13018-025-06419-2)
  • [L2] Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. (10.1302/0301-620x.106b6.bjj-2023-0889.r1)
  • [L2] Pain at baseline was the strongest predictor for pain at follow-up in both body regions. (10.1186/s12891-020-3096-9)
  • [L3] The authors propose a value of 2.1 to represent the Patient-Acceptable Symptom State (PASS) threshold for the Numeric Rating Scale (NRS) pain score in this population. (10.1016/j.jhsa.2024.07.020)
  • [L1] In addition to a shared 'natural history', enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design. (10.1186/1471-2474-15-68)
  • [L2] Marines with a history of back pain are at risk of further back pain episodes, emphasizing the importance of early preventive actions. (10.1186/s12891-016-1172-y)
  • [L3] The changes were not related to a history of neck trauma, nor to current pain, but more likely due to long-lasting pain. (10.1186/1471-2474-9-90)
  • [L2] Pain self-efficacy did not moderate the relationship between treatment and outcome. (10.1177/17585732221105562)
  • [L4] Pain serves as a critical warning sign for impending complications such as compartment syndrome; masking pain with pharmacological means can lead to missed diagnoses, severe disability, and other adverse outcomes. (10.2106/00004623-200109000-00020)
  • [L3] Multidimensional Pain Inventory subgroup classification is substantially stable in chronic back pain patients when compared to other diagnostic groups and other examiner-based subgroup Classification Systems. (10.1186/1471-2474-13-155)
  • [L2] Greater self-efficacy was the best determinant of satisfaction with pain relief. (10.1007/s11999-014-3660-4)
  • [L3] Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. (10.1186/1471-2474-9-152)
  • [L4] Insight into patients' pain experience may help to choose and develop appropriate diagnostic instruments. (10.1371/journal.pone.0182207)
  • [L3] Targeting self-efficacy contributes to fast improvement in functional status for selected and motivated patients with persistent chronic low back pain. (10.1186/s12891-021-04637-3)
  • [L4] Initial treatment is conservative, with as many as two-thirds of patients improving, while surgery is indicated for incapacitating pain recalcitrant to nonoperative management. (10.5435/jaaos-d-24-00513)
  • [L5] Early diagnosis is often challenging because the initial signs and symptoms frequently are subtle. (10.5435/00124635-200808000-00006)
  • [L3] Pain in the thigh continues to be a concern and may well indicate a poor prognosis. (10.2106/00004623-199410000-00005)
  • [L4] Patients with longer pain duration indicated greater self-efficacy and patients with higher pain disability and depression exhibited lower self-efficacy. (10.1186/s13018-019-1535-9)
  • [L2] Furthermore, the exploratory results of this study suggest that it could be an effective treatment to reduce pain intensity and improve on self-reported quality of life in these patients, although a future randomized clinical trial is needed to determine its effectiveness. (10.1186/s12891-025-08294-8)
  • [L3] The presence of comorbidities is associated with poorer care for low back pain. (10.1186/s12891-018-2316-z)
  • [L3] A 1.4-cm improvement on a 10-cm pain visual analog scale indicates patients have achieved a clinically important improvement in their pain levels. (10.1016/j.jse.2009.03.021)
  • [L3] Pain relief occurs immediately following infusion with functional improvements observed 4 weeks later. (10.1186/s12891-018-2252-y)
  • [L3] This study found baseline and outcome differences between neck pain subgroups classified using the Quebec Task Force Classification System. (10.1186/s12891-015-0609-z)
  • [L3] A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP. (10.1016/j.jht.2014.02.003)
  • [L4] Management plans that efficiently simultaneously address back and additional coexistent pain sites may maximize treatment functional benefits, address patient functional goals in life and mitigate disability. (10.1186/s12891-024-07393-2)
  • [Case_report] Operative intervention offers positive outcomes and symptom relief compared to non-operative treatment. (10.1186/s13018-024-04860-3)
  • [L4] Approaches to primary outcome assessment in back pain need re-assessment. (10.1186/s12891-015-0534-1)
  • [L2] Our results suggest that there is an association between hip-pelvic kinematics and future LBP. (10.1186/s12891-020-03376-1)
  • [L4] If nonoperative treatment fails to relieve symptoms, surgical decompression can be offered as an option. (10.1177/03635465000280010501)
  • [L2] A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. (10.1002/ejp.615)
  • [L2] The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. (10.2106/00004623-200109000-00002)
  • [L4] This highlights the need for better counseling and innovative nonopioid pain management protocols. (10.1016/j.jseint.2020.12.019)
  • [L2] The use of proxy-reported patient-reported outcomes might better characterize functional impairment and pain in a vulnerable patient population and could decrease selection bias in outcomes research. (10.5435/jaaos-d-17-00644)
  • [L2] Operative management resulted in greater symptom relief and functional improvement compared to nonoperative management. (10.2106/00004623-200001000-00002)
  • [L4] Long-term sequelae and morbidity are primarily due to delays in diagnosis and inadequate treatment. (10.5435/00124635-200105000-00003)
  • [L5] Conservative treatment should be considered as a first-line option if symptoms can be controlled to prevent unnecessary surgery. (10.1186/s12891-025-08822-6)
  • [L4] Women were, generally, more likely to report pain than men, and while pain was reported as more long-lasting in older groups, prevalence estimates changed surprisingly little over age. (10.1186/1471-2474-10-39)
  • [L3] Therefore, age and pain sensation should be considered as important parameters for the recommendation for TSA. (10.1186/s13018-022-03137-x)
  • [L4] The study concludes that a two-stage approach using latent class analysis is preferable to a single-stage approach for identifying subgroups of patients with low back pain, as it yields more distinct and clinically meaningful subgroups. (10.1186/s12891-017-1411-x)
  • [L4] Four subgroups of lumbo-pelvic flexion kinematics were revealed with an unequal distribution among people with and without a history of persistent LBP. (10.1186/s12891-018-2233-1)
  • [L4] Kinematic MRI demonstrated dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation. (10.1186/s13018-023-03745-1)
  • [L1] Our findings suggest that currently available devices are capable of assessing spinal posture with good accuracy in the clinical setting. (10.1186/s12891-019-2430-6)
  • [L3] The Quebec Task Force categories identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. (10.1186/s12891-017-1495-3)
  • [L4] The identified classes provide unique information on pain location and intensity in emerging adults. (10.1186/s12891-023-06412-y)
  • [L4] These findings underpin the concurrent validity of the Quebec Task Force Classification, though the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. (10.1186/1471-2474-13-236)
  • [L4] Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. (10.1186/s12891-017-1562-9)
  • [L2] Our findings suggest that the MRI abnormalities examined are not major predictors of outcome in patients with LBP. (10.1186/1471-2474-12-234)
  • [L4] MPI subgroup classification showed significant differences in score changes for pain, mental health and coping. (10.1186/1471-2474-12-145)
  • [L4] Differences in characteristics of nonspecific low back pain between elderly and young patients were successfully detected using the new detailed VAS scoring system. (10.1155/2012/680496)
  • [L5] Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, and direct surgical repair can yield high rates of pain relief in recalcitrant cases. (10.2106/00004623-200402000-00027)
  • [L4] Whilst pain medication use varied with pain severity, different medication types reported broadly aligned with OA guidelines. (10.1186/s12891-024-07854-8)
  • [L4] Diagnostic delay may occur because of atypical spinal radiographs if the patient reports only back pain but no fever. (10.1186/s12891-022-05749-0)
  • [L5] There has never been a properly conducted trial of surgery versus active conservative care, so it is still not known whether early surgery or active physiological management offers the better chance for recovery. (10.1302/0301-620x.105b4.bjj-2023-0111)
  • [L1] Early MRI is associated with increased length of disability in patients with acute LBP without red flags. (10.1186/s12891-021-04863-9)
  • [L5] Imaging techniques, especially MRI, are invaluable tools for clinicians in identifying this condition, assessing its extent, and guiding treatment. (10.1186/s13018-025-05781-5)
  • [L5] From the perspective of finite element analysis, the cervical vertebrae after PPECD treatment showed good biomechanical performance and stability. (10.1186/s13018-019-1113-1)
  • [L3] Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain. (10.1186/s12891-020-03462-4)
  • [L3] The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties. (10.1186/1749-799x-9-11)
  • [L4] Rasterstereography is a valuable tool for the dynamic evaluation of spinal posture and pelvic position, which can also be used to quantify motion in the spine and therefore it has the potential to improve the understanding and treatment of spinal pathologies. (10.1186/s13018-020-01825-0)
  • [L3] Early screening for incorrect postures and angle of trunk rotation could be an effective and economical strategy to predict the severity of the condition. (10.1186/s13018-024-04767-z)
  • [L1] This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. (10.1186/s12891-017-1549-6)
  • [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. (10.1186/1471-2474-15-152)
  • [L3] Although MRI findings are common in asymptomatic people and the association between single MRI findings and LBP is often weak, our results suggest that subgroups of multiple and severe lumbar MRI findings have a stronger association with LBP than those with milder degrees of degeneration. (10.1186/s12891-018-1978-x)
  • [L4] In type I, disc degeneration was accelerated by regional kyphosis, while in type II, excessive mechanical stress was directly loaded at the thoracolumbar apex. (10.1186/s12891-021-04033-x)
  • [L3] Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning. (10.1016/j.jse.2019.04.001)
  • [L4] The results demonstrate that pain reduction did not alter lumbar range of motion, angular velocity, angular acceleration or movement irregularity questioning the role of pain in lumbar kinematics. (10.1186/1471-2474-15-304)
  • [L4] The modality is useful for identifying referred pain sources and avoiding unnecessary irradiation by limiting CT acquisition to cases with abnormal SPECT findings. (10.1186/s13018-016-0402-1)
  • [L4] We identified predictive MRI signs in patients with symptomatic AC osteoarthritis. (10.1016/j.jse.2018.01.001)
  • [L2] The tests are not very helpful in clarifying the cause of radicular pain and are therefore inaccurate for guidance in the diagnostic workup of the patients. (10.1186/1471-2474-14-206)
  • [L5] Large lumbar spine fusion or high-grade lumbosacral transitional vertebrae (LSTV) is probably the most deleterious to spinal mechanics and outcomes, while low-grade LSTV with maintained spinopelvic motion is perhaps not critical for outcomes following hip arthroscopy. (10.1016/j.arthro.2023.04.004)
  • [L3] The findings suggest that photographs provide valid and reliable indicators of the position of the underlying spine in sitting. (10.1186/1471-2474-9-113)
  • [L5] The authors encourage emphasizing severe pain with limited range of motion as a reliable clinical sign and congratulate Baldwin et al. for creating a diagnostic algorithm that uses only one laboratory test and no advanced imaging. (10.2106/jbjs.16.00152)
  • [L4] The kinematic analysis of dentists illustrates typical patterns of postures during tasks that are essential to the dental treatment of patients, with higher angular values in the cervical and thoracic spine during treatment compared to other dental tasks. (10.1186/s12891-016-1288-0)
  • [L3] It is not necessary to perform extensive diagnostic studies to evaluate every patient who has scoliosis and back pain. (10.2106/00004623-199703000-00007)
  • [L4] Repeat imaging may be necessary as MRI is not always definitive for early stage injuries. (10.1177/0363546506296519)
  • [L2] Significant risk factors for developing low back pain were a previous history of low back pain and presence of low back pain symptoms at the start of work. (10.1186/s12891-018-2037-3)
  • [L3] HIZ sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain. (10.1186/s13018-018-1010-z)
  • [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
  • [L3] The VAS score (average pain during the past 4 weeks) was a prognostic factor for NeP. (10.1186/s12891-016-1311-5)
  • [L4] Follow-up ranging from eighteen to twenty-five months revealed complete resolution of the sciatica in all patients. (10.2106/00004623-198567060-00006)

See Also

References

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[32] Regional differences in lumbar spinal posture and the influence of low back pain. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-152

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[34] Targeting self-efficacy more important than dysfunctional behavioral cognitions in patients with longstanding chronic low back pain; a longitudinal study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04637-3

[35] Cotrel-dubousset instrumentation for the correction of adolescent idiopathic scoliosis. Long-term results with an unexpected high revision rate. 2012.

[36] Atlantoaxial Osteoarthritis: An Overlooked Condition. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00513

[37] Cauda Equina Syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200808000-00006

[38] Pain in the thigh following total hip replacement with a porous-coated anatomic prosthesis for osteoarthrosis. A five-year follow-up study.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199410000-00005

[39] The factors driving self-efficacy in intractable chronic pain patients: a retrospective study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1535-9

[40] A multidisciplinary pain management program for patients with chronic low back pain: a randomized, single-blind, controlled, feasibility study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08294-8

[41] What is the association between the presence of comorbidities and the appropriateness of care for low back pain? A population-based medical record review study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2316-z

[42] Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2009.03.021

[43] Cyclic bisphosphonate therapy reduces pain and improves physical functioning in children with osteogenesis imperfecta. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2252-y

[44] In a secondary care setting, differences between neck pain subgroups classified using the Quebec task force classification system were typically small – a longitudinal study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0609-z

[45] Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2014.02.003

[46] Considerations beyond spine pain: do different co-occurring lower body joint pains differentially influence physical function and quality of life ratings?. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07393-2

[47] Paralumbar compartment syndrome, a rare sequela of deadlifting: a case report and review of current literature. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04860-3

[48] Primary outcome measure use in back pain trials may need radical reassessment. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0534-1

[49] Performance in dynamic movement tasks and occurrence of low back pain in youth floorball and basketball players. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03376-1

[50] Coracoid Impingement. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280010501

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[53] What do patients think about opioids? a survey of patient perceptions regarding pain control after shoulder surgery. JSES International. 2021. DOI: 10.1016/j.jseint.2020.12.019

[54] Reliability of Proxy-reported Patient-reported Outcomes Measurement Information System Physical Function and Pain Interference Responses for Elderly Patients With Musculoskeletal Injury. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00644

[55] Long-Term Disability and Return to Work Among Patients Who Have a Herniated Lumbar Disc: The Effect of Disability Compensation. The Journal of Bone and Joint Surgery-American Volume*. 2000. DOI: 10.2106/00004623-200001000-00002

[56] Acute Hematogenous Osteomyelitis in Children. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200105000-00003

[58] Spontaneous regression of large-sized lumbar facet synovial cysts: two case reports and literature review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08822-6

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[60] Radiological changes in shoulder osteoarthritis and pain sensation correlate with patients’ age. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03137-x

[61] Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1411-x

[62] Subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2233-1

[63] Dynamic evaluation of the cervical spine by kinematic MRI in patients with cervical spinal cord injury without fracture and dislocation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03745-1

[64] The role of wearables in spinal posture analysis: a systematic review. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2430-6

[65] Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1495-3

[66] Musculoskeletal pain latent classes and biopsychosocial characteristics among emerging adults. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06412-y

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[68] Associations between disc space narrowing, anterior osteophytes and disability in chronic mechanical low back pain: a cross sectional study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1562-9

[69] Chapter 36 Back Pain, Disk Disease, Spondylolysis, and Spondylolisthesis. 2020.

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[82] Dynamic spinal posture and pelvic position analysis using a rasterstereographic device. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01825-0

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[86] The association between subgroups of MRI findings identified with latent class analysis and low back pain in 40-year-old Danes. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1978-x

[87] Analysis of sagittal profile and radiographic parameters in symptomatic thoracolumbar disc herniation patients. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04033-x

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[91] Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.01.001

[92] Accuracy of physical examination for chronic lumbar radiculopathy. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-206

[93] Editorial Commentary: Restrictions in Spinal Motion Result in Lower Outcome Scores After Hip Arthroscopy. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.04.004

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[95] When in Doubt, Examine the Patient. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.16.00152

[96] Kinematic analysis of work-related musculoskeletal loading of trunk among dentists in Germany. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1288-0

[97] The Prevalence of Back Pain in Children Who Have Idiopathic Scoliosis. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199703000-00007

[98] Sacral Stress Fractures: Magnetic Resonance Imaging Not Always Definitive for Early Stage Injuries. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506296519

[99] The relationship between low back pain and professional driving in young military recruits. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2037-3

[100] Factors associated with lumbar disc high-intensity zone (HIZ) on T2-weighted magnetic resonance image: a retrospective study of 3185 discs in 637 patients. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-1010-z

[101] Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b6.bjj-2016-0569.r1

[103] Neuropathic pain in patients with rotator cuff tears. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1311-5

[104] Intraspinal synovial cyst causing sciatica.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567060-00006

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2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.