What are the first-line treatments for low back pain?

Patient Education on Low Back Pain

Core Message to Deliver

Reassure patients that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment, and emphasize that staying active and continuing normal activities within pain limits is more effective than bed rest for recovery. 1, 2

Essential Educational Points

Expected Course and Prognosis

• Most patients experience rapid improvement in pain, disability, and ability to return to work within the first month, with the majority achieving substantial recovery by 6 weeks. 1
• Minor flare-ups may occur in the subsequent year, but this is normal and does not indicate treatment failure. 3
• Up to one-third of patients may report persistent symptoms beyond this timeframe, which requires reassessment and additional interventions. 1

Activity Recommendations

• Patients must remain active and continue ordinary activities within the limits permitted by pain—this is a strong recommendation based on moderate-quality evidence. 1, 2
• Bed rest should be explicitly avoided as it is associated with increased disability and worse outcomes. 1, 3, 4
• Early return to work should be encouraged, as it reduces long-term disability. 3, 4
• For workers with subacute low back pain, brief individualized educational interventions can reduce sick leave. 1

Self-Care Options

First-line self-care measures:

• Apply superficial heat using heating pads or heated blankets for short-term pain relief in acute low back pain. 1, 2
• Use a medium-firm mattress rather than a firm mattress, as firm mattresses are less likely to lead to improvement. 1, 5
• Continue stretching exercises and ice application for painful areas. 3

What to avoid:

• Lumbar supports have insufficient evidence to recommend as self-care options. 1
• Cold packs lack sufficient evidence for routine recommendation. 1

When to Seek Further Care

Red flags requiring immediate medical attention:

• Severe or progressive neurologic deficits (weakness, numbness, loss of bowel/bladder control). 1, 2
• Suspicion of serious underlying conditions such as cancer, infection, or spinal fracture. 1, 3
• Symptoms of cauda equina syndrome. 3

Timing for reassessment:

• If no improvement occurs after 6 weeks of conservative management, patients should return for re-evaluation and consideration of imaging or additional interventions. 5, 3
• For persistent symptoms lasting 4-12 weeks (subacute phase), additional nonpharmacologic therapies should be considered. 2

Psychosocial Factors

• Assess and address psychosocial risk factors that predict chronic disabling back pain, including depression, anxiety, job dissatisfaction, and fear-avoidance beliefs. 1, 2
• Depression commonly coexists with chronic back pain and should be screened for and treated appropriately. 2
• Cognitive-behavioral approaches may be beneficial for patients at risk of chronicity. 1

Treatment Expectations

Nonpharmacologic Approaches

• Exercise therapy is a cornerstone of treatment for chronic low back pain, with moderate evidence of efficacy. 1, 2
• Spinal manipulation, acupuncture, massage therapy, and yoga have proven benefits for both acute and chronic low back pain. 1
• The magnitude of pain benefits from these therapies is typically small to moderate and generally short-term, with effects on function being smaller than effects on pain. 2

Pharmacologic Options

• For acute pain requiring medication, acetaminophen (up to 3000mg/day) or NSAIDs like ibuprofen are first-line options. 1, 2
• Acetaminophen has a more favorable safety profile but is slightly less effective than NSAIDs for pain relief. 1
• NSAIDs should be used at the lowest effective dose for the shortest duration due to cardiovascular and gastrointestinal risks. 1

Common Pitfalls to Avoid

• Do not pursue routine imaging (X-rays, MRI, CT) for nonspecific low back pain without red flags, as findings are often nonspecific and do not improve outcomes. 1, 2
• Avoid overreliance on passive treatments like prolonged rest or medications alone, as active strategies such as exercise are associated with decreased disability. 6
• Do not expect complete pain elimination—realistic goals focus on functional improvement and return to normal activities. 2
• Systemic corticosteroids should be avoided as they have not shown greater efficacy than placebo. 2, 5

Prevention Strategies

• Educate patients on proper body mechanics and safe back exercises for injury prevention. 3
• Public health programs should emphasize prevention of low back pain in high-risk populations. 6
• For patients with acute back pain, use screening tools to identify those at risk of progression to chronic pain and implement targeted treatment strategies. 7