What is the approach to managing a patient with Low Back Pain (LBP)?

Approach to Low Back Pain Management

The management of low back pain should follow a stratified care approach using tools like STarT Back to identify risk levels, with first-line treatment including topical NSAIDs, non-pharmacological interventions, and patient education while avoiding opioids. 1, 2

Initial Assessment and Stratification

• Use the STarT Back tool at 2 weeks from pain onset to stratify patients into low, medium, or high risk for developing persistent disabling pain 1
• Risk stratification directs resources appropriately:
  • Low-risk patients: Self-management
  • Medium-risk patients: Physiotherapy and patient-centered management
  • High-risk patients: Comprehensive biopsychosocial assessment and management 1

First-Line Treatments

Non-Pharmacological Interventions

• Encourage patients to stay active rather than resting 1
• Heat therapy is effective for acute back pain 2
• Manual therapy such as spinal manipulation for back pain with radiculopathy 2
• Consider massage, acupressure, and mind-body approaches (mindfulness, tai chi, yoga) 2

Pharmacological Management

• Topical NSAIDs with or without menthol gel (superior benefit-harm ratio) 2
• Oral NSAIDs or acetaminophen as second-line options 2
• Short course of muscle relaxants (cyclobenzaprine) for 2-3 weeks maximum 2
• Avoid opioids (including tramadol) as first-line therapy 2

Persistent Pain Management (4-6 weeks)

• Reassess if patient does not return to normal activity within 4-6 weeks 3
• Consider specific acupressure or TENS for patients not responding to first-line therapy 2
• Focus on conservative treatment for at least 6 weeks before considering more invasive options 2
• Implement multidisciplinary treatment programs for chronic pain (>3 months) 4

Imaging and Specialist Referral

• Radiographs and laboratory tests are generally unnecessary except when serious causes are suspected 3
• Consider MRI without contrast for patients with radiating pain to assess neural compression 2
• Consider specialist referral if:
  • Pain persists beyond 4-6 weeks despite conservative treatment 2
  • Progressive neurological deficits are present
  • Cauda equina syndrome is suspected (requires immediate surgical investigation) 3
  • Intractable pain is resistant to conservative treatment 3

Special Considerations for Chronic LBP (>3 months)

• Implement aerobic fitness and endurance training 4
• Consider behavioral treatment to prevent LBP from becoming chronic 4
• For specific diagnoses, consider:
  • Zygapophysial joint pain (15-40% of cases): May benefit from radiofrequency neurotomy 5
  • Sacroiliac joint pain (about 20% of cases): Emerging treatments available 5
  • Internal disc disruption (over 40% of cases): Emerging treatments available 5

Pitfalls and Caveats

• Overreliance on imaging can lead to unnecessary interventions; most LBP is non-specific 6
• Recommendation for paracetamol/acetaminophen for acute LBP has been challenged by recent evidence 6
• Bed rest should be limited to 2-3 days maximum for patients with acute radiculopathy 3
• Widespread pain associated with LBP indicates worse prognosis compared to localized LBP 4
• Opioids should be avoided except in cases of severe traumatic injuries or when other therapies are contraindicated 2

Work and Function Considerations

• Use "fit notes" to provide information on how the condition affects ability to work 1
• Implement vocational rehabilitation services when appropriate 1
• Focus on improving activity/participation and maintaining work capacity 4