What is the detailed management approach for low back pain?

Management Approach and Causes of Low Back Pain

The management of low back pain should follow a stepped care approach, beginning with self-care strategies, avoiding bed rest, providing appropriate pain relief, and implementing patient education, with risk stratification using the STarT Back tool at 2 weeks to guide further treatment decisions. 1, 2

Causes of Low Back Pain

Low back pain can be categorized into several types:

• Non-specific low back pain: Most common form (85-90% of cases)
• Radicular pain: Due to nerve root compression
• Specific pathological causes: Including:
  • Fractures
  • Malignancy
  • Infection
  • Inflammatory disorders
  • Cauda equina syndrome
  • Visceral or metabolic abnormalities
  • Deformity

Common structural sources include:

• Myofascial pain
• Facet joint pain
• Sacroiliac joint pain
• Discogenic pain
• Spinal stenosis
• Failed back surgery syndrome 3

Initial Management (0-2 weeks)

1. Rule out red flags:

   • Severe or progressive neurological deficits
   • Suspected cauda equina syndrome
   • History of cancer
   • Unexplained weight loss
   • Fever or recent infection
   • Recent trauma
   • Pain that worsens when supine or at night 1, 2

2. Initial treatment approach:

   • Advise reactivation and avoid bed rest
   • Provide appropriate pain relief:
     • NSAIDs if not contraindicated
     • Topical analgesics for localized pain
     • Heat therapy and massage therapy as adjuncts
   • Implement self-care strategies and patient education
   • Review and assess improvement within 2 weeks 1, 2

Risk Stratification (at 2 weeks)

Use the STarT Back tool to assess severity, impact, and risk of persistent disability:

• Low-risk patients:

  • Encourage self-management
  • Provide reassurance
  • Continue current management if improving

• Medium-risk patients:

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

• High-risk patients:

  • Refer for comprehensive biopsychosocial assessment
  • Specialized physiotherapy with skills to address psychosocial factors 1, 2

Follow-up Management (2-12 weeks)

• Review no later than 12 weeks
• For radicular pain:
  • Consider neuropathic pain medications
  • Consider image-guided epidural steroid injections
  • Coordinate with rehabilitation during periods of pain relief 2
• For persistent non-specific low back pain:
  • Exercise programs with individual tailoring, supervision, stretching, and strengthening
  • Consider manipulation for acute and sub-acute non-specific LBP
  • Consider cognitive behavioral therapy for pain coping strategies 1, 2, 4

Specialist Management (if no improvement by 12 weeks)

• Biopsychosocial assessment within a multidisciplinary team context
• Self-care/management with individualized stepped approach
• Complex medication management including careful use of opioids (lowest effective dose for shortest time) and neuropathic pain medications
• High-intensity cognitive behavioral therapy
• Consider referral to specialist spinal surgical service if appropriate 1, 2

Special Considerations

For Radicular Pain

• Refer earlier (within 2 weeks) if severe radicular pain or neurological deficits
• Less severe radicular pain should be referred to specialist services no later than 3 months
• MRI should only be requested by clinicians able to interpret the images 2

For Chronic Pain

• Multidisciplinary biopsychosocial rehabilitation is recommended
• Intensive interdisciplinary rehabilitation may be beneficial
• Workplace accommodations should be considered:
  • Anti-fatigue mats
  • Adjustable height work surfaces
  • Proper lifting techniques training
  • Regular position changes and breaks 2, 5

Common Pitfalls to Avoid

1. Overreliance on imaging: MRI has high sensitivity but low specificity for spinal pain and should not be routinely ordered at primary care level 2, 6

2. Prolonged bed rest: This may worsen the condition rather than improve it 1, 2

3. Physical therapy for all approach: Not effective for all patients, hence the importance of risk stratification 1

4. Inadequate self-management support: Patients often report limited information on self-management; direct support, reinforcement, and frequent contact are usually needed 1

5. Neglecting psychosocial factors: These are crucial in the development of chronic pain and disability 1, 2, 5

By following this structured approach to low back pain management, clinicians can provide evidence-based care that addresses both the physical and psychosocial aspects of the condition, improving outcomes and reducing the risk of chronic disability.