What are the initial treatment recommendations for adult back pain?

Initial Treatment Recommendations for Adult Back Pain

For acute low back pain (<4 weeks), clinicians should recommend superficial heat (moderate-quality evidence) as first-line nonpharmacologic therapy, with massage, acupuncture, or spinal manipulation as alternatives (low-quality evidence). 1

Assessment and Classification

Before initiating treatment, categorize the patient's back pain into one of three categories:

• Nonspecific low back pain
• Back pain potentially associated with radiculopathy or spinal stenosis
• Back pain potentially associated with another specific spinal cause 2

Key Assessment Elements

• Document pain characteristics (onset, duration, location, quality, severity)
• Screen for red flags: age >50 years, history of cancer, unexplained weight loss, fever, trauma, saddle anesthesia, bladder/bowel dysfunction, progressive neurological deficits 2
• Evaluate for yellow flags: psychosocial risk factors, fear-avoidance behaviors, depression 2

Treatment Recommendations by Duration

Acute Low Back Pain (<4 weeks)

1. Nonpharmacologic options (first-line):

   • Superficial heat (good evidence for moderate benefits) 1
   • Spinal manipulation (fair evidence for small to moderate benefits) 1
   • Massage or acupuncture (low-quality evidence) 1

2. Pharmacologic options (if needed):

   • NSAIDs (moderate-quality evidence) 1
   • Skeletal muscle relaxants (moderate-quality evidence) 1

3. Important principles:

   • Advise patients to stay active and continue ordinary activities within pain limits 3
   • Avoid bed rest 4, 3
   • Reassure that 90% of episodes resolve within 6 weeks regardless of treatment 3

Subacute Low Back Pain (4-12 weeks)

• Continue nonpharmacologic approaches
• Consider graded-activity exercise programs, especially in occupational settings 5
• Consider referral for goal-directed manual physical therapy if no improvement after 1-2 weeks 3

Chronic Low Back Pain (≥12 weeks)

1. Nonpharmacologic options (first-line):

   • Exercise therapy 1, 4
   • Multidisciplinary rehabilitation 1
   • Acupuncture, mindfulness-based stress reduction (moderate-quality evidence) 1
   • Tai chi, yoga, motor control exercise, cognitive behavioral therapy, spinal manipulation (low-quality evidence) 1

2. Pharmacologic options (second-line):

   • NSAIDs (first-line pharmacologic option) 1, 6
   • Tramadol or duloxetine (second-line pharmacologic options) 1, 6
   • Opioids only after failure of other treatments and only if benefits outweigh risks 1

Special Considerations

Medication Cautions

• NSAIDs: Use with caution in patients with cardiovascular disease or renal impairment 2
• Muscle relaxants (e.g., cyclobenzaprine): Start with 5mg dose in patients with mild hepatic impairment; not recommended in moderate to severe hepatic impairment 7
• Elderly patients: Use slower progression of exercise intensity and careful medication management due to higher risk of side effects 2

Imaging Recommendations

• Routine imaging is not recommended for nonspecific low back pain 2, 6
• Consider imaging only if:
  • Red flags are present
  • Neuromuscular deficit exists
  • Pain does not resolve with conservative therapy after 6 weeks 6, 3

Follow-up and Reassessment

• Consider using the STarT Back tool to categorize patients into low, medium, or high risk for developing chronic pain 2
• Follow up within 48-72 hours for patients with severe symptoms 2
• If symptoms persist beyond 6 weeks despite appropriate management, consider additional imaging or specialist referral 2

Key Pitfalls to Avoid

1. Recommending bed rest (associated with worsening disability) 4
2. Relying solely on passive treatments (medications, rest) instead of active strategies 4
3. Ordering routine imaging for nonspecific low back pain 2, 6
4. Starting with opioids before trying other treatment options 1
5. Failing to address psychosocial factors that may contribute to pain chronicity 2

Remember that most patients with acute low back pain improve over time regardless of treatment 1, and early active management with nonpharmacologic approaches is associated with better outcomes.