What are the guidelines for managing back pain?

Guidelines for Managing Back Pain

For most patients with back pain, nonpharmacologic treatments should be tried first, with pharmacologic options reserved for those who do not respond adequately, and opioids considered only after failure of other treatments when benefits outweigh risks.

Classification of Back Pain

• Back pain is classified based on duration: acute (<4 weeks), subacute (4-12 weeks), and chronic (>12 weeks) 1
• Initial assessment should classify pain as nonspecific, potentially associated with radiculopathy/spinal stenosis, or potentially associated with another specific spinal cause 2
• Most patients with acute back pain have self-limited episodes that resolve on their own; many do not seek medical care 1

Diagnostic Approach

• Diagnostic imaging should NOT be routinely obtained for nonspecific low back pain 1, 2
• MRI or CT should only be performed when severe/progressive neurologic deficits are present, serious underlying conditions are suspected, or for persistent symptoms in patients who are candidates for surgery or epidural steroid injection 1, 2
• Avoid overuse of imaging, as findings on MRI or CT are often nonspecific and do not improve outcomes 2

Treatment for Acute and Subacute Low Back Pain (<12 weeks)

• Most patients improve over time regardless of treatment 1

• First-line approach should be nonpharmacologic treatment with:

  • Superficial heat (moderate-quality evidence) 1
  • Massage, acupuncture, or spinal manipulation (low-quality evidence) 1
  • Advice to remain active and avoid bed rest 1, 2
  • Reassurance about favorable prognosis 2

• If pharmacologic treatment is desired:

  • NSAIDs (like ibuprofen) or skeletal muscle relaxants (moderate-quality evidence) 1, 3
  • Acetaminophen (up to 3000mg/day) is also recommended 2
  • Avoid systemic corticosteroids as they have not shown greater efficacy than placebo 2

Treatment for Chronic Low Back Pain (>12 weeks)

• First-line approach should be nonpharmacologic treatment with:

  • Exercise therapy 1
  • Multidisciplinary rehabilitation 1
  • Acupuncture, mindfulness-based stress reduction (moderate-quality evidence) 1
  • Tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence) 1

• For inadequate response to nonpharmacologic therapy:

  • NSAIDs as first-line pharmacologic therapy 1
  • Tramadol or duloxetine as second-line therapy 1
  • Consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors as part of multimodal strategy 2
  • Opioids should only be considered after failure of all other treatments and only if potential benefits outweigh risks after discussion with patient 1

Special Considerations

• Screen for and treat depression as it commonly coexists with chronic back pain 2
• Consider gabapentin for radicular symptoms 2
• Avoid continuous or intermittent traction as it has not shown effectiveness for radicular symptoms 2
• Consider MRI and specialist referral if symptoms persist beyond 4 weeks despite conservative management 2, 4

Common Pitfalls to Avoid

• Overuse of imaging for nonspecific back pain 2
• Overreliance on opioids 2, 5
• Prescribing benzodiazepines without time limitations 2
• Using systemic corticosteroids which lack evidence of efficacy 2
• Recommending bed rest 1, 2
• Failure to address psychosocial factors that may contribute to chronic pain 1, 2

Monitoring and Follow-up

• For patients with acute back pain, improvement in pain, disability, and return to work typically occurs rapidly in the first month 1
• Up to one-third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode 1
• For persistent symptoms, reassess for specific causes and consider referral to specialist if symptoms continue beyond 4-6 weeks of conservative treatment 4, 6