What is the first line treatment for back pain?

First-Line Treatment for Back Pain

For acute and subacute low back pain, first-line treatment should be nonpharmacologic therapy with superficial heat, massage, acupuncture, or spinal manipulation. If medication is desired, NSAIDs should be used as first-line pharmacologic treatment. 1, 2

Classification of Back Pain

Back pain is typically classified by duration:

• Acute: less than 4 weeks
• Subacute: 4-12 weeks
• Chronic: more than 12 weeks

First-Line Treatment Approach

Nonpharmacologic Treatments (First-Line)

For acute/subacute back pain:

• Remain active and avoid bed rest 1, 2
• Apply superficial heat (moderate-quality evidence) 1
• Consider massage, acupuncture, or spinal manipulation (low-quality evidence) 1
• Proper body mechanics for lifting and daily activities 2

For chronic back pain:

• Exercise therapy (moderate-quality evidence) 1, 3
• Multidisciplinary rehabilitation 1
• Acupuncture, mindfulness-based stress reduction 1
• Tai chi, yoga, motor control exercise 1
• Progressive relaxation, electromyography biofeedback 1
• Low-level laser therapy, cognitive behavioral therapy 1

Pharmacologic Treatments (If Needed)

For acute/subacute back pain:

• NSAIDs as first-line pharmacologic treatment (moderate-quality evidence) 1, 2
• Muscle relaxants as an alternative (moderate-quality evidence) 1
• Topical NSAIDs with or without menthol gel 2
• Acetaminophen for those who cannot take NSAIDs 2

For chronic back pain (after inadequate response to nonpharmacologic therapy):

• NSAIDs as first-line pharmacologic treatment 1, 2
• Tramadol or duloxetine as second-line therapy 1
• Muscle relaxants (e.g., cyclobenzaprine 5-10mg at bedtime) if pain remains inadequately controlled after 2-4 weeks 2
• Consider neuropathic pain medications (gabapentin, pregabalin) if radicular component is prominent 2

Risk Stratification

The STarT Back tool is recommended for early risk stratification (at 2 weeks from pain onset) 2:

• Low risk: Encourage self-management
• Medium risk: Refer to physiotherapy with patient-centered management plan
• High risk: Refer to physiotherapy with comprehensive biopsychosocial assessment

When to Consider Imaging

Imaging is NOT recommended for routine evaluation of back pain. According to the American College of Radiology, imaging should only be considered in the following situations 1, 2:

• After 6 weeks of failed conservative management
• Presence of red flags:
  • Suspected cauda equina syndrome
  • Progressive neurological deficits
  • Suspected infection or malignancy
  • History of significant trauma
  • Osteoporosis
  • Chronic steroid use
  • Elderly patients with history of trauma

Special Considerations

• Elderly patients: Slower progression of exercise intensity and careful medication management due to higher risk of side effects 2
• Cardiovascular disease or renal impairment: Special attention with NSAID use 2
• Most cases of back pain improve within 6-8 weeks with conservative treatment 2, 3

When to Consider Specialist Referral

Consider referral if:

• Symptoms persist beyond 6 weeks despite appropriate management 2, 4
• Presence of progressive neurological deficits 1, 2
• Cauda equina syndrome (medical emergency) 2
• Intractable pain despite 6 weeks of comprehensive conservative management 2

Common Pitfalls to Avoid

• Recommending bed rest (this can worsen outcomes) 1, 2
• Ordering routine imaging for uncomplicated back pain 1, 2
• Early use of opioids (should only be considered after failure of other treatments and with careful risk-benefit assessment) 1
• Neglecting psychosocial factors that may contribute to pain chronicity 2, 3
• Failing to encourage continued activity and self-management 1, 2