What are the recommended management strategies for lower back pain?

Management of Lower Back Pain

For lower back pain, a multimodal approach including physical therapy, NSAIDs for short-term use, and psychological interventions is strongly recommended, with opioids reserved only as a last resort for limited duration. 1

Initial Assessment and Classification

• Categorize patients using the STarT Back tool to identify risk for developing persistent disabling pain 1:

  • Low risk: Minimal psychosocial factors - Encourage self-management
  • Medium risk: Some psychosocial factors - Refer to physiotherapy with patient-centered plan
  • High risk: Significant psychosocial factors - Comprehensive biopsychosocial assessment

• Identify if pain is:

  • Nonspecific low back pain (most common)
  • Associated with radiculopathy or spinal stenosis
  • Referred from non-spinal source
  • Associated with specific spinal cause 2

First-Line Treatments (0-2 weeks)

1. Physical interventions:

   • Encourage continued activity as tolerated (avoid bed rest) 1
   • Apply heat therapy (moderate-quality evidence shows improvement in pain relief) 1
   • Consider ice for painful areas 3

2. Pharmacological management:

   • NSAIDs for up to one week (first-line) 1
   • Acetaminophen as an alternative 1
   • Consider muscle relaxants for acute back pain with muscle spasm (short-term only) 1

Ongoing Management (Beyond 2 weeks)

Physical/Restorative Therapy

• Strongly recommended as part of multimodal strategy for low back pain 4
• Focus on active interventions (supervised exercise) rather than passive interventions 1
• Consider McKenzie exercises for pain radiating below the knee 3
• Stretching exercises and proper body mechanics instruction 3

Psychological Interventions

• Cognitive behavioral therapy, biofeedback, and relaxation training provide relief for periods ranging from 4 weeks to 2 years (Category A2 evidence) 4, 1
• Consider mindfulness-based stress reduction 1
• Supportive psychotherapy and group therapy may be beneficial 4

Pharmacological Management

For persistent pain:

• Anticonvulsants (e.g., α-2-delta calcium-channel antagonists) for neuropathic pain 4
• Antidepressants:
  • Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine for various chronic pain conditions 4, 1
  • Selective serotonin reuptake inhibitors (SSRIs) specifically for diabetic neuropathy 4
• Opioids: Should only be prescribed as a last resort and for very limited duration 1

Advanced Interventions for Refractory Pain

• Multidisciplinary rehabilitation for persistent pain not responding to other interventions 1
• Acupuncture may be considered (low-quality evidence shows moderate improvement) 1
• Massage moderately improves short-term pain and function for subacute back pain 1

When to Refer for Specialized Care

• Red flag symptoms (cauda equina syndrome, suspected cancer, infection, or vertebral fracture)
• Severe radicular pain with neurological deficits
• Nonspecific low back pain failing to respond to standard therapies after 3 months 1
• Significant psychiatric comorbidity requiring specialized mental health intervention 1

Imaging Considerations

• Avoid routine imaging for nonspecific back pain
• Delay lumbar spine radiography for at least 1-2 months
• MRI or CT is appropriate only for patients with back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause 1

Common Pitfalls to Avoid

• Prescribing bed rest (worsens outcomes) 1, 3
• Routine imaging for nonspecific back pain (low yield, high cost) 1
• Long-term use of muscle relaxants or opioids (risk of dependence with limited evidence of benefit) 1
• Focusing solely on pain relief without addressing functional improvement 4
• Neglecting psychosocial factors that contribute to pain chronicity 1

Remember that 90% of low back pain episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur in the subsequent year 3.