What are the management options for back pain?

Management Options for Back Pain

The management of back pain should follow a stepped care approach, starting with self-care strategies and progressing to more specialized interventions based on patient response and risk stratification. 1

Initial Management (First 2 Weeks)

• Advise reactivation and avoid bed rest 1, 2
• Provide appropriate pain relief 1
  • First-line: NSAIDs if not contraindicated 2
  • Topical analgesics for localized pain 2
  • Muscle relaxants (cyclobenzaprine) for up to 2-3 weeks if muscle spasm present 3
• Implement self-care/management and patient education 1
  • Online resources, telephone helplines, paper-based information 1
  • Heat therapy and massage therapy 2
• Review and assess improvement within 2 weeks 1

Risk Stratification (After 2 Weeks)

After 2 weeks, use the STarT Back tool to assess severity, impact, and risk of persistent disability 1, 2:

1. Low-risk patients:

   • Encourage self-management
   • Continue current management if improving
   • Proceed to ongoing evaluation pathway

2. Medium-risk patients:

   • Refer to standard physiotherapy
   • Develop patient-centered management plan

3. High-risk patients:

   • Refer for comprehensive biopsychosocial assessment
   • Specialized physiotherapy with skills to provide biopsychosocial approach
   • Review no later than 12 weeks

Non-Pharmacological Options

• Exercise therapy - most effective when individually tailored, supervised, and includes stretching and strengthening 2, 4
• Spinal manipulation - recommended for acute and sub-acute non-specific LBP 5
• Massage therapy - soft tissue manipulation using hands or mechanical devices 1, 2
• Heat therapy - provides temporary relief 2
• Cognitive behavioral therapy - particularly for high-risk patients or those with persistent pain 2
• Progressive relaxation techniques - deliberate tensing and relaxation of muscles 1
• Yoga - specific body positions, breathing techniques, and mental focus 1

Pharmacological Options

• NSAIDs - first-line if not contraindicated 2
• Muscle relaxants (cyclobenzaprine) - for relief of muscle spasm for short periods (2-3 weeks) 3
  • Start with 5mg dose in patients with mild hepatic impairment
  • Not recommended for moderate to severe hepatic impairment
• Duloxetine - may be beneficial for chronic back pain 6
• Neuropathic pain medications - for radicular pain 2
• Opioids - use lowest effective dose for shortest time possible with close monitoring 2

Specialized Management (If No Improvement After 12 Weeks)

• Consider referral to a specialist pain center/specialist spinal center 1
• Biopsychosocial assessment performed in a multidisciplinary team context 1
• Complex medication management including appropriate use of opioids and neuropathic pain medications 1
• High-intensity cognitive behavioral therapy 1
• Consider referral to specialist spinal surgical service if appropriate 1

Special Considerations for Radicular Pain

• Earlier referral (within 2 weeks) for severe radicular pain or neurological deficits 2
• Consider image-guided epidural steroid injections 2
• Coordinate with rehabilitation during periods of pain relief 2

Lifestyle Modifications

• Stay active rather than resting 2, 7
• Workplace accommodations - anti-fatigue mats, adjustable height surfaces, proper lifting techniques 2
• Modify specific activities - avoid prolonged standing, take regular breaks, limit heavy lifting 2
• Weight management for those with elevated BMI 2

Common Pitfalls to Avoid

• Relying on passive treatments rather than active approaches 7, 4
• Ordering routine imaging without red flags 2, 6
• Prolonged bed rest which may worsen the condition 2, 7
• Extended use of muscle relaxants beyond 2-3 weeks 3
• Overlooking psychosocial factors that may contribute to pain chronicity 1, 6

Remember that keeping active despite low back pain is "healthy," and most patients can manage their short-term and even longer-term symptoms with appropriate guidance 7.